State Institution Compliance
Agreement
Researchers at public institutions in the United
States that cannot sign the Standard Indemnification
Agreement must complete the State Institution Compliance Agreement in order
to obtain specimens identified as biohazardous. Researchers at public
institutions that are unable to accept the terms of either the Standard
Indemnification Agreement or the State Institution Compliance Agreement must
complete the Waiver of Indemnification Agreement; such
individuals will not be able to obtain specimens that are known to contain an
infectious agent. As a Receiving Party of blood specimens from the
National, Lung, and Blood Institute's Biologic Specimen Repository, the
Recipient Institution, __________________________________
______________________________________________________________________________
agrees to be responsible for any claims, costs,
damages, or expenses resulting from any injury (including death), damage or
loss that may arise from the possession and use of the specimens or any
derivative thereof by the Receiving Party to the extent permitted under the
laws of this State. The individual executing this agreement on behalf of the
Recipient Institution warrants that the individual has full authority to do so,
and to thereby bind the Recipient Institution.
| ______________________________ |
_____________________________ |
| *Officer of Institution or Company
(signature) |
Requestor (Signature) |
| ______________________________ |
______________________________ |
| Printed Name |
Printed Name |
| ______________________________ |
______________________________ |
| Title |
Title |
| ______________________________ |
______________________________ |
| Institution |
Institution |
| ______________________________ |
______________________________ |
| Date |
Date |
*This officer cosigning above must be capable of
legally binding the institution
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Department of Health
and Human Services
National
Institutes of Health
National Heart, Lung, and Blood
Institute