Confidential Disclosure Agreement (CDA) Request
Incomplete request form will delay the agreement review process.
Please be aware that the Center for Medical Innovation only processes requests for Confidentiality Agreements related to current or anticipated intellectual property collaborations or commercialization. For Confidentiality Agreements related to research activities or collaborations,
please submit your request to the Office of Research Affairs
.
Penn State College of Medicine Contact Information
Primary Investigator (PI) Name
PI Email
Lab Coordinator Name
Coordinator Email
Department
Please select...
Anesthesiology and Perioperative Medicine
Biochemistry and Molecular Biology
Cellular and Molecular Physiology
Comparative Medicine
Dermatology
Emergency Medicine
Family and Community Medicine
Humanities
Medicine
Microbiology and Immunology
Neural and Behavioral Sciences
Neurology
Neurosurgery
Obstetrics and Gynecology
Ophthalmology
Orthopaedics and Rehabilitation
Otolaryngology - Head and Neck Surgery
Pathology and Laboratory Medicine
Pediatrics
Pharmacology
Physical Medicine and Rehabilitation
Psychiatry and Behavioral Health
Public Health Sciences
Radiation Oncology
Radiology
Surgery
Urology
Other
Contact Phone #
Lab Address
List Any Co-Investigator(s)
List any Penn State Co-Investigator(s):
External Party Contact Information
Collaborating Institution / Company Name
Collaborator Name
Email
Contract Negotiator Name
Email
Address Type:
United States
International
United States Address
Street Address
City/State/ZIP Code
International Address
Address
Town, Region / Country
If you will be exchanging information with more than one external party under this CDA (multi-party CDA), please provide a list of additional parties:
Please Provide Complete Answers to the Following
Purpose of Exchange (please provide a specific explanation as to why this agreement is required):
Which parties will be disclosing Confidential Information?
External Party Only
Penn State Only
Both External Party and Penn State
Description of Confidential Information you expect to receive from External Party:
Description of Penn State Confidential Information you expect to disclose to External Party (
Note that Confidential Information can include invention disclosures, past results, and future developments
):
Is there a Penn State invention/technology disclosure or patent application related to the Topic of Conversation?
Yes
No
List Penn State Disclosure Number or Title:
Will there be any exchange of physical material(s) as part of this agreement?
Yes
No
Please describe:
Are you aware of any other related agreement(s) between Penn State and the External Party?
Yes
No
Which department negotiated the original agreement(s)
How long do you expect to exchange Confidential Information with the other party? (Agreement Term Date; standard is one(1) year)
Please select...
1 Year
2 Years
3 Years
4 Years
5 Years
Do you (the Principal Investigator) or Co-Investigator(s) have a potential conflict of interest related to this request (i.e., cofounder of the company, a consultant of the company, or affiliated with the company in any way)?
Yes
No
Please explain:
Deadline to have the agreement signed (if applicable)
Reason for the deadline:
Access to Confidential Information
Do you need to further share any Confidential Information you will receive from the other party with anyone else outside of your lab?
Yes
No
Please explain why and list the individual(s):
Will you be sharing any Confidential Information received with your students (postdoc, graduate or undergraduate)?
Yes
No
Please explain:
Could any of the Confidential Information you plan to share be restricted by third party rights, such as sponsor rights (i.e., this could be the case if you have industry funding on a related subject)?
Yes
No
Unknown
Please explain:
Export Compliance Information
Are you (the Principal Investigator) a U.S. citizen or lawful permanent resident?
Yes
No
Will you be sharing External Party Confidential Information with any Penn State employees (including faculty, staff and graduate students) who are foreign nationals that are not U.S. citizens or green card holders?
Yes
No
Which country(ies) are the individual(s) from?
Is any Confidential Information you will be disclosing subject to a Technology Control Plan?
Yes
No
Upload Documents
Attach supporting documentation related to the exchange of Confidential Information (i.e.: Agreement draft, relevant correspondence, or other documentation).
File Upload:
Digital Signature
Please put any additional comments or notes here
By entering the name of the principal investigator below, I certify that they are fully aware of and confirm all the information stated above.
PI Name
Date
Person Filling Out Form (if not PI)