Standard Indemnification Agreement
Researchers at private universities, foundations,
and companies, or at state institutions that
can accept the wording of the Standard Indemnification
Agreement must complete this form in order to
obtain specimens from the NHLBI Biologic Specimen
Repository. An alternate
State Institution Compliance Agreement for researchers
at US public institutions that cannot sign this
Standard Indemnification Agreement is provided.
Researchers at institutions that are unable to
accept the terms of the Indemnification or Compliance
Agreement must complete the
Waiver of Indemnification Agreement; such individuals
will not be able to receive specimens that are
known to contain an infectious agent. US Government
employees are not required to submit an indemnification
agreement.
As a Receiving Party of biologic specimens from the
National, Heart, Lung, and Blood Institute's Biologic Specimen Repository, the
Recipient Institution, _____________________________
________________________________________________________________________
agrees to indemnify and hold harmless the United States, the Contractor, their
suppliers and contributors, from 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. 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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