J-1 EXCHANGE VISITOR PROGRAM PROSPECTIVE EXCHANGE VISITOR QUESTIONNAIRE

Office of International Programs University of Kansas Medical Center 3901 Rainbow Blvd., Mail Stop 3033 5010 Wescoe Kansas City, KS 66160 Phone: 913-588-1480 Fax: 913-588-1462 Mail Stop 3033, 3901 Rainbow Blvd., Kansas City, KS 66160 J-1 EXCHANGE VISITOR PROGRAM PROSPECTIVE EXCHANGE VISITOR QUESTIONNAIRE OFFICE OF INTERNATIONAL PROGRAMS (OIP) CONTACT INFORMATION Alexandria Harkins International Student and Exchange Visitor Adviser, ARO, DSO Email: aharkins2@kumc.edu Phone: 913-588-1460 Irina Aris Assistant Director of Inbound Programs, RO, DSO Email: iaris@kumc.edu Phone: 913-588-1485 WHAT IS THE J-1 EXCHANGE VISITOR PROGRAM? The University of Kansas Medical Center (KUMC) is designated by the U.S. Department of State (DOS) to sponsor J-1 Exchange Visitors (EVs) in the categories of Professor, Research Scholar, Short-Term Research Scholar, Student, and Student Intern. The J-1 Exchange Visitor Program was designed by the DOS to foster mutual understanding as well as cultural and educational exchanges between the United States and other countries. In the Federal Register, 22 CFR Part 62 establishes the J-1 Exchange Visitor Program and outlines its various regulatory requirements and parameters. All EVs and sponsoring institutions must adhere to these regulatory requirements and parameters. Sponsoring institutions have the authority to issue DS-2019 documents (Certificates of Eligibility for Exchange Visitor Status (J-Nonimmigrant) which allows participants or EVs to apply or change status to a J-1 nonimmigrant visa. REQUEST PROCESS 1. Sponsoring department submits the following to the OIP: Completed DS-2019 request form Deemed Export Questionnaire OIP Fee 2. OIP contacts prospective EV and provides exchange visitor questionnaire 3. Prospective EV submits the following to sponsoring department: EV questionnaire Supporting documents (i.e. degree certificates, passport copies, immunizations, proof of English proficiency) OIP receives department request documents OIP provides EV with questionnaire EV submits requested documents to OIP Upon receipt of DS-2019, EV pays SEVIS fee and schedules a visa appointment with U.S. Embassy or files for a change of status Sponsoring department mails (via courier service) original DS-2019 to EV Upon receipt of documents OIP issues DS-2019 (5-business day turnaround) ARRIVAL AT KUMC EVs have to arrive at KUMC no sooner or later than 30 days of their program start date. Upon arrival at KUMC, EVs will complete an orientation and checkin appointment with OIP. At check-in, EVs must provide the following items to OIP in order to have their J-1 SEVIS record validated: 1. Current DS-2019 2. U.S. address 3. Passport with I-94 (available only after arrival at www.cbp.gov/i94) 4. Visa stamp 5. Proof of health insurance, medical evacuation and repatriation insurance that meet U.S. Department of State requirements HEALTH INSURANCE REQUIREMENTS The U.S. Department of State (DOS) requires all J-1 and J-2 Exchange Visitors to carry health insurance throughout their program in the United States. As a sponsor, the University of Kansas Medical Center monitors exchange visitor compliance. Failure to comply with these regulations can result in loss of status. SUMMARY OF STATE DEPARTMENT HEALTH INSURANCE MINIMUM REQUIREMENTS GENERAL: ACCIDENT AND ILLNESS Minimum of $100,000 per accident or illness for medical benefits Maximum co-payment of 25% Maximum deductible of $500 per accident or illness MEDICAL EVACUATION Minimum of $50,000 REPATRIATION Minimum of $25,000 Page 1

PROSPECTIVE EXCHANGE VISITOR QUESTIONNAIRE CHECKLIST Passport identification pages Copies of degree certificates. If not in English, a certified translation should be included. Proof of English proficiency document Completed immunizations checklist o Copies of immunization records (in English) Proof of funding o Must be provided by incoming exchange visitor if not receiving KUMC funding or being partially funded by outside sources. If applicable, passport identification pages for each J-2 dependent If applicable, previous J status documents such as: o DS-2019 o J Visa stamp o I-94 Please submit the completed questionnaire and supporting documents to the Office of International Programs. PROSPECTIVE EXCHANGE VISITOR BIOGRAPHICAL INFORMATION GENDER: DATE OF BIRTH (mm/dd/yyyy): SOCIAL SECURITY NUMBER (if applicable): MALE FEMALE CITY OF BIRTH: PROVINCE/STATE OF BIRTH: COUNTRY OF BIRTH: EMAIL ADDRESS: COUNTRY OF PERMANENT RESIDENCY: TELEPHONE NUMBER: CURRENT ADDRESS (WHERE EXCHANGE VISITOR IS PHYSICALLY LOCATED OR LIVING; CANNOT BE PLACE OF EMPLOYMENT): ADDRESS (street name and number): CITY: PROVINCE/STATE: COUNTRY: ZIP/POSTAL CODE: PERMANENT ADDRESS: ADDRESS (street name and number): CITY: PROVINCE/STATE: COUNTRY: ZIP/POSTAL CODE: CURRENT EMPLOYMENT INFORMATION: POSITION HELD IN HOME COUNTRY: OCCUPATION FIELD: NAME OF LAST EMPLOYER IN HOME COUNTRY: LOCATION OF LAST EMPLOYER IN HOME COUNTRY: Page 2

PROSPECTIVE EXCHANGE VISITOR EDUCATION DEGREE FIELD OF STUDY YEAR OF COMPLETION UNIVERSITY BACHELOR S DEGREE CITY AND COUNTRY MASTER S DEGREE DOCTORAL DEGREE (PH.D., ED.D) PROFESSIONAL DEGREE (M.D., J.D., DVM) PROSPECTIVE EXCHANGE VISITOR IMMIGRATION HISTORY List your complete immigration history, including each visa classification held, and dates present in the United States in each visa classification (attach additional paper, if needed). VISA TYPE PURPOSE START DATE END DATE SPONSORING DEPARTMENT: POSITION TITLE: EXCHANGE VISITOR PROGRAM AND POSITION INFORMATION SPONSORING SUPERVISOR: NAME: EXCHANGE VISITOR CATEGORY: Exchange Visitor Category** Description of Activity Minimum Program Duration Maximum Program Duration Research Scholar Engage in research 3 weeks 5 years Professor Engage in teaching and lecturing 3 weeks 5 years Short-Term Research Scholar Engage in lecturing, observing, consulting, training, or demonstrating special skills 1 day 6 months **OIP is also designated in sponsoring internationals on J-1 Student and J-1 Intern categories. The J-1 Student and the J-1 Intern categories have separate request forms; please visit the OIP website at http://www.kumc.edu/international-programs/scholars.html for more information. Page 3

FUNDING INFORMATION INSTRUCTIONS: If the exchange visitor will receive non-kumc funding or will provide personal funds, please complete the funding information below. J-1 PROGRAM MINIMUM FUNDING REQUIREMENTS POSTDOCTORAL FELLOW POSITIONS: $32,000 per year ($2667 per month) It is strongly encouraged to follow the NIH/NRSA salary guidelines when appointing Postdoctoral Fellows. To sponsor an individual as a Postdoctoral Fellow on the J-1 Research Scholar visa category, the prospective J-1 must be a KUMC paid employee only. An exception can be made by the Office of International Programs when the prospective Postdoctoral Fellow on a J-1 visa receives a fellowship or scholarship award from a recognized organization or government agency which is eligible for renewal for the duration of the Postdoctoral Fellowship opportunity. Minimum funding must meet the salary guidelines listed above. ALL OTHER POSITIONS UNDER J-1 PROGRAM: $23,000 per year ($1917 per month) + An additional $3180 for each accompanying J-2 dependent Proof of funding documents must be copies of originals or certified copies, printed on official letterhead or equivalent. If the document is not in English, a certified translation must be attached to the original copy. o If the Exchange Visitor is funded through a grant awarded to KUMC, please provide more information below (i.e. source, etc.). o If exchange visitor is funded through a scholarship, home government grant, or other institution, please provide information below and attach evidence that shows amount and duration of support, and that the specified support is for the Exchange Visitor to participate in a program at KUMC. Documents can be copies of the original; printed on official letterhead or equivalent. If not in English, please include a certified translation. o If Exchange Visitor is funded through personal funds, please provide information below and attach proof: A bank statement (in English or a certified translation) that shows available funds for the proposed exchange visit. Proof of funding cannot be older than 6 months from submission of this request. PLEASE INDICATE THE SOURCE OF FUNDING: KUMC PAID (means funding will be paid by the University of Kansas Medical Center although the original source may be from a grant) NON KUMC PAID (means funding is provided by an outside source such as a scholarship, grant, personal funds, etc.) TOTAL AMOUNT OF FUNDING (USD): DURATION OF FUNDING (MONTHS): $ ADDITIONAL INFORMATION ABOUT FUNDING: AMOUNT (IN USD) TYPE (i.e. grant, scholarship, etc.) SOURCE (i.e. institution issuing funds) FUNDING COUNTRY OF ORIGIN PLEASE NOTE: Office of International Programs should be notified of any changes to the exchange visitor s funding amount and source of funding. Page 4

DEPENDENT INFORMATION Complete this part if you will have dependents accompanying you for the duration of your program at KUMC. Repeat this page as necessary for additional family members. Dependents will receive his or her own DS-2019 document(s) to obtain J-2 visa status. J-2 dependents can only be the spouse or child/children of the J-1 exchange visitor. Children over the age of 21 are not eligible for J-2 status. Please note, if your spouse or child will only temporarily visit you in the United States, it may be best to obtain a visitor s visa rather than a J-2 visa. J-2 dependents must comply and maintain health insurance meeting U.S. Department of State requirements at all times while their record is in active status. DEPENDENT 1: RELATIONSHIP TO EXCHANGE VISITOR (J-1): SPOUSE CHILD GENDER: MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: Is the dependent currently in the United States? YES NO Has the dependent ever held J-1 or J-2 status? YES NO If yes, indicates dates each status held: DEPENDENT 2: RELATIONSHIP TO EXCHANGE VISITOR (J-1): SPOUSE CHILD GENDER: MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: Is the dependent currently in the United States? YES NO Has the dependent ever held J-1 or J-2 status? YES NO If yes, indicates dates each status held: DEPENDENT 3: RELATIONSHIP TO EXCHANGE VISITOR (J-1): SPOUSE CHILD GENDER: MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: Is the dependent currently in the United States? YES NO Has the dependent ever held J-1 or J-2 status? YES NO If yes, indicates dates each status held: ACKNOWLEDGEMENT By signing this document, I attest that all information included in this request document is true and correct. Prospective EV Signature: Date: Name: Page 5

ATTESTATION OF ENGLISH PROFICIENCY The U.S. Department of State Subpart A regulations require that The exchange visitor possesses sufficient proficiency in the English language, as determined by an objective measurement of English language proficiency, successfully to participate in his or her program and to function on a day-to-day basis. [22 CFR 62.11(a)(2)] Effective January 1, 2015, an incoming Exchange Visitor is responsible for providing documented proof of English proficiency that meets the regulations in [22 CFR 62.11(a)(2)]. Please indicate below which of the following documented proof is being included with this request to show the Exchange Visitor s English Proficiency. A recognized English language test. o TOEFL o IELTS o Cambridge English Language Assessment *Minimum test scores have to meet intermediate levels. **If teaching or lecturing is involved, language test results should meet the University of Kansas Medical Center s TOEFL and IELTS minimum requirements. Please visit OIP s website for more information on the minimum requirements at http://www.kumc.edu/international-programs/academic-english-requirements.html. Signed documentation from an academic institution or English language school. A documented interview conducted either in-person or videoconferencing by the sponsoring department and the Director of International Programs, Kimberly Connelly. English proficiency requirements can only be waived in the following situations: Incoming exchange visitor provides documented proof that he or she previously earned a degree from a U.S. college or university. Incoming exchange visitor provides documented proof that he or she previously earned a degree or is from a country listed on the Exemption List (http://www.kumc.edu/international-programs/academic-english-requirements.html). The Exchange Visitor and the Sponsoring Supervisor by signing this form attest to the English proficiency requirements specified by U.S. Department of State regulations. Furthermore, the Exchange Visitor agrees to comply and provide necessary documentation to show proof of compliance with the requirements listed above. Exchange Visitor Signature Date For Office Use Only Interview Conducted Either In-Person or Videoconferencing Approved Not Approved Kimberly Connelly, M.A.T. Date Director of International Programs, Signature Page 6

IMMUNIZATIONS The Office of International Programs DATE OF BIRTH (mm/dd/yyyy): PHONE NUMBER: EMAIL ADDRESS: Please attach copies of lab reports of the following immunization records. Documentation of immunizations must be in English. If not in English, please include a translation. If you are unable to obtain any of these immunizations in your home country or prior to arrival, you may have the option to complete them at the KUMC Occupational Health clinic, please contact the Office of International Programs for more information. 1. MMR (Measles, Mumps, Rubella) Two doses, 28 days apart OR IgG antibody (titer) 2. Tdap (Tetanus, Diphtheria, Pertussis) Vaccination 3. Varicella (Chicken Pox) Two doses, 28 days apart OR IgG antibody (titer) 4. TB Test IF there is a positive skin test, please provide an X-ray not older than 6 months. o The X-ray report must state evaluation was to rule out active TB IF there is a negative skin test, you will be required to have an additional Quantiferon TB Test (QFT) upon arrival at KUMC 5. Annual Influenza Vaccine Mandatory during flu season 6. Hepatitis B Antibody (Aniti HBs) Required only if there is reasonable risk of direct contact with blood or body fluids *note: patient contact is not permitted* By signing below, I agree to release any information relevant to my immunizations, obtained the Occupational Health Clinic, to the Office of International Programs. SIGNATURE: --------------------------------------------------------------------------------------------------------------------------------------------- -FOR OFFICE USE ONLY- Do not write below this line - RESPONSIBLE PARTY FOR THE FEES ASSOCIATED WITH THE OUTSTANDING VACCINATIONS: INTERNATIONAL INDIVIDUAL DEPARTMENT ( ) OFFICE OF INTERNATIONAL PROGRAMS OFFICE OF INTERNATIONAL PROGRAMS APPROVAL DATE: ADVISOR NAME: SIGNATURE: DATE: OCCUPATIONAL HEALTH CLINIC RECOMMENDATIONS BLOOD DRAW (for immune status of specific disease) Rubella Titer Rubeola Titer Mumps Titer VZV (Chicken Pox) Titer Hepatitis B Titer Other: VACCINATIONS (if not immune to specific disease) MMR (Measles, Mumps, Rubella) Vaccination VZV (Chicken Pox) Vaccination Hepatitis B Vaccination Other: VACCINATIONS (recommended) Influenza (Flu) Vaccine Tdap (Tetanus, Diphtheria, Pertussis) Vaccination TB TEST TB Blood Test (QFT) Chest X-ray For any questions or concerns regarding this request please contact the Office of International Programs Irina Aris (iaris@kumc.edu; 913-588-1485) Alexandria Harkins (aharkins2@kumc.edu; 913-5881460) Assistant Director of Inbound Programs, RO, DSO International Student and Exchange Visitor Advisor, ARO, DSO