OSP Contract Intake Form

What is the deadline date?*

This CDA/NDA is for:*

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Please describe what you need the CDA/NDA for and provide any relevant documentation you have in the attachment upload field.*

Please explain what you need assistance with and our team will reach out.*

Please provide any relative documents in the File Upload field.

Service Provider/Consultant Information

If this agreement is with a sole proprietor, single person LLC, or individual, please upload the Tax Determination Form in the Document Upload field at the bottom of this form.

Sponsor Information

Entity/Institution Information

External Party Information

Name:*

This is the name of the service provider, consultant, sponsor, institution, external party, or pass-through entity.

Address:*

This is the address of the service provider, consultant, sponsor, institution, external party, or pass-through entity.

Point of Contact's Name and Title:*

This is the name and title of the Point of Contact of the service provider, consultant, sponsor, institution, external party, or pass-through entity.

Point of Contact's Email:*

This is the email of the Point of Contact of the service provider, consultant, sponsor, institution, external party, or pass-through entity.

Point of Contact's Phone Number:

This is the phone number of the Point of Contact of the service provider, consultant, sponsor, institution, external party, or pass-through entity.

Phone

Project Details:

Project Title:*

Funder/Sponsor:*

This is the Prime Funder of the project.

Coeus Lite Proposal #:*

If the project is internally funded, enter 00000.

If this request is for a Master Research Agreement for future proposals, enter n/a.

*If the request is for sponsored research, a valid Coeus Lite Proposal # is REQUIRED.*

Fund #:*

If not available or if nonfunded project, enter 00000.

Contract Details

Start Date:*

End Date:*

Where are the services being provided?*

Please enter physical address.

Contract Initial Amount:*

This amount covers funding on the start date to end date indicated above.

Certification of Funding:*

There must be enough funding to cover this contract. Please confirm the fund's availability prior to submitting this request.

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Will intellectual property (IP)/inventions be created under this agreement?*

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Will there be any Drexel, joint, or third-party existing IP (background IP) used in this project?*

Select all that apply.

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Publication: Publication of results of this project will be managed as indicated:*

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Disclosure of Confidential Information:*

Please indicate if there is confidential information being disclosed and how.

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What type of data will be shared?*

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Will there be any sharing of protected data (Protected Health Information-PHI/Personally Identifiable Information-PII) or involve Human Subjects?*

Please select all that apply.

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IRB Approval #:*

Please provide the IRB Approval Letter in the Attachment Upload field. If you do not have IRB Approval yet, please enter 00000.

IRB Approval Expiration Date:

This approval expiration date must be a future date.

Will the research involve animals?*

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IACUC Approval #:*

Please provide the IACUC Approval Letter in the Attachment Upload field. If you do not have IACUC Approval yet, please enter 00000.

IACUC Approval Expiration Date:

This approval expiration date must be a future date.

Documentation Provided

Please ensure all necessary attachments are uploaded or delays may occur.

Scope of Work (Attach in File Upload):

Detailed Budget (Attach in File Upload):

Tax Determination Form (Tax Office IC Approval) (Attach in File Upload):

Budget Justification (Attach in File Upload):

New Agreement Template Provided by Sponsor (if applicable, Attach in File Upload):

IRB Approval Letter:

IACUC Approval Letter:

Any Relevant Previously Fully Executed Agreements (if applicable, Attach in File Upload):

This includes any prior CDAs, NDAs, ICAs, etc. related to the request.

Governing Agreement- Fully Signed (if applicable, Attach in File Upload)

Additional Comments:

File Upload

Drag and drop files here or

By checking this box, I acknowledge that all information I have given is accurate.*

Send My Response Notice:*

Please note: In order to receive a copy of your response, you must check the "Send me a copy of my responses" box below and enter your email address. If you have an additional person (e.g. the PI, department admin) you would like to send the responses to, please forward your email from SmartSheet to the desired recipient(s) once it arrives in your inbox.

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Requestor Information

Service Provider/Consultant Information

Sponsor Information

Entity/Institution Information

External Party Information

Project Details:

Contract Details

Documentation Provided