Contact information of the individual providing the Material: (?)

• First name:
  Last name:
  Phone:
  Email Address: Note: A copy of this submission will be sent to this email address.
  
  Title:
  Department:

Are you the Principal Investigator? (?)

• Yes   No

  Name of Principal Investigator

Is the PI an HHMI Investigator? (?)

• Yes   No

Please specify the PI's affiliation: (?)

• • FAS
  • HMS
  • HSPH
  • HSDM
  • SEAS
  • WYSS

Contact information of the Recipient (including email and institution): (?)

Is the Recipient located outside of the United States? (?)

• • Yes  Transfer may require an Export Control license. We will be in touch if we need further information.
  • No

Specific name of Material(s) being provided: (?)

Is the Material a mouse? (?)

• Yes   No

  1. What is the name of the gene or allele mutation that make the organism unique?
  2. What would be the mouse strain background?

Is the Material (including any data) of human origin? (?)

• • Yes OTD may need to add language into the MTA for the Recipient's awareness.
    Is the Material human embryonic stem cells? (?) Yes   The Recipient will be notified about Harvard ESCRO requirements. No
  • No

Does handling the Material require more than the standard laboratory precautions or safety measures (i.e., studies involving recombinant DNA, synthetic nucleic acids, viral pathogens, bacterial pathogens, prions, biological toxins, human blood and tissues, non-human primate blood and tissues, clinical gene transfer, and/or clinical xenotransplanation)? (?)

• • YesOTD may need to add language into the MTA for the Recipient's awareness.
  • No

Has the Material been published? (?)

• Yes   No

  • How soon does your lab intend to publish on the Material?
    • 3-6 Months
    • 1 Year
    • More We can preserve your right to publish first for up to 2 years.
  • Do you intend to collaborate with the Recipient and, therefore, is co-publication anticipated?

    Yes   No

Will you be providing any confidential information along with the Material? (?)

• Yes   No

Does the Material incorporate or is it a modification of material received from a third party? (?)

• Yes   No

  What is the name of the third-party material and what is the name of the provider organization?

Have you submitted a Report of Invention to OTD or have we filed patents on the Material? (?)

• • Yes Case Number:
  • No

Is the Material the subject of any other agreement (license, sponsored research, or other)? (?)

• Yes   No
• Please describe:

Which best describes the permitted use of the Material by Recipient? (?)

• Any academic research purposes A specific research plan
  Evaluation: The Recipient will test the Material for a brief time period (e.g. 30 days to 1 year) simply to see if it would pursue a future research collaboration or a Material License with Harvard.
  
  Material License: The Recipient will pay Harvard a license fee in order to use the Material independently for commercial purposes.
  
  Internal Research: The Recipient will use the Material solely for basic internal research (i.e. no commercial use).

  Will you be actively collaborating with the Recipient on its internal research? Yes No

  
  
  None of the above

In addition to the Material, will you and the other party share any of the following? (Check any that apply) (?)

• • Lab space
  • Lab members
  • Funding
  • Resulting data
  • Additional material(s)
  • None of the above

Do you want to ask for any reimbursement to compensate for preparation and shipping costs? (?)

• Yes
  Please indicate an appropriate fee:
  No

Please provide any other pertinent email correspondence or information related to the request that you think will help expedite the process.

Please provide email addresses for any additional individuals you wish to have included on correspondence related to this request.