REQUEST FOR A DS-2019

Mail Stop 3033, 3901 Rainbow Blvd., Kansas City, KS 66160 REQUEST FOR A DS-2019 INSTRUCTIONS: The request form must be completed and signed by the hiring department. The DS-2019 Request form and supporting documents should be submitted to the Office of International Programs (OIP). OIP will notify the hiring department when the DS-2019 will be issued and ready for pick-up. Office of International Programs University of Kansas Medical Center 3901 Rainbow Blvd., Mail Stop 3033 5010 Wescoe Kansas City, KS 66160 Email: InternationalProgs@kumc.edu Phone: 913-588-1480 Fax: 913-588-1462 OFFICE OF INTERNATIONAL PROGRAMS CONTACT INFORMATION Alexandria Harkins International Student and Exchange Visitor Adviser, ARO, DSO Email: aharkins2@kumc.edu Phone: 913-588-1460 Irina Aris International Exchange Visitor and Employee Advisor, RO, DSO Email: iaris@kumc.edu Phone: 913-588-1485 PURPOSE OF REQUEST Select the purpose of DS-2019 request. Initial DS-2019 Request for Exchange Visitor from KUMC Transfer of DS-2019 to KUMC from another U.S. institution Type of Exchange Visitor Category being requested: 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 3 weeks 5 years lecturing Short-Term 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 1

BIOGRAPHICAL INFORMATION Family Name: Given Name: Middle Name: Gender: Male Female Social Security Number (if available): of Birth (mm/dd/yyyy): City of Birth: Province/State of Birth: Country of Birth: Country of Citizenship: Country of Permanent Residency: Current Address (where exchange visitor is physically located or living; cannot be place of employment): City: Province/State: Country: Permanent Address: City: Province/State: Country: Email Address: Telephone Number: Occupation in Home Country: Name of Last Employer in Home Country: Location of Last Employer in Home Country: Page 2

EDUCATION Degree Field of Study Year of Completion Bachelor s Degree Master s Degree Doctoral Degree (Ph.D., Ed.D) Professional Degree (M.D., J.D., DVM) University City and Country 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 End SPONSORING DEPARTMENT INFORMATION Department in which the activity will occur: Physical (campus address) location of the activity: Individual who will directly supervise the visitor: Department Contact or Coordinator: Name Title Phone Name Title Phone If activity will take place at the VA Medical Center, please fill out the following: The sponsoring supervisor is affiliated with the University of Kansas Medical Center. Yes No If yes, please provide title and department at KUMC: Page 3

POSITION INFORMATION Position Title: Anticipated Program dates (mm/dd/yyyy): Beginning Ending Please describe briefly (1-2 sentences) the activity or research that the exchange visitor will engage in: Please note: The hiring department and exchange visitor should notify and obtain approval from OIP of any changes to the exchange visitor s position, department, physical location, or activity. FUNDING INFORMATION Minimum funding requirements: $18,620 for the J-1; an additional $3,180 for each dependent If the Exchange Visitor is funded through a grant, please provide more information below (i.e. source, duration, etc.). 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. Total amount = USD $ directly from the following source(s): for month(s), which is the duration of the program. The Exchange Visitor will be paid Amount (in USD) Source Country of Issuance USD $ USD $ USD $ USD $ Please note: The hiring department and exchange visitor should immediately report to OIP any changes to the exchange visitor s funding amount and source of funding. Page 4

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, videoconferencing, or telephone 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 Supervisor Signature Page 5

DEPENDENT ATTESTATION Exchange visitor regulations hold the sponsoring institution of the J-1 principal responsible for the monitoring of J-2 dependents. Accordingly, the Office of International Programs requires that the host department or institution approve of any dependents, whether accompanying the Visitor or arriving separately. The hiring department agrees to offer reasonable assistance to the OIP in complying with these regulations, including, but not limited to, the maintenance of mandatory health, medical evacuation and repatriation insurance, the monitoring of arrival /departure information, and information pertaining to employment or study by the J-2 dependent. As the official responsible for the oversight of the exchange visitor, I support the Visitor s dependent(s) accompanying him/her. I accept responsibility for said dependents as for the Visitor, and will assist the OIP in a reasonable manner to ensure that KUMC and the Visitor maintain compliance with DOS regulations. (Note: If you do not sign this statement, it will not affect the eligibility of the principal exchange visitor for sponsorship through KUMC. However, no dependents will be issued a DS2019, nor will one be issued at a later date until a new statement of support is signed.) Supervisor Signature DEPENDENT INFORMATION If Exchange Visitor will have J-2 dependents, please fill out information below. J-2 dependents can only be the spouse of J-1 exchange visitor and children. Each J-2 dependent must hold his/her own DS-2019 form in order to obtain a visa and maintain status once in the United States. Repeat this page as necessary for additional family members. Family Name: Given Name: Middle Name: of Birth (mm/dd/yyyy): City of Birth: Country of Birth: Country of Citizenship: Relationship to Exchange Visitor (J-1): Wife Husband Daughter Son 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, dates in J status: from to Family Name: Given Name: Middle Name: of Birth (mm/dd/yyyy): City of Birth: Country of Birth: Country of Citizenship: Relationship to Exchange Visitor (J-1): Wife Husband Daughter Son 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, dates in J status: from to Family Name: Given Name: Middle Name: of Birth (mm/dd/yyyy): City of Birth: Country of Birth: Country of Citizenship: Relationship to Exchange Visitor (J-1): Wife Husband Daughter Son 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, dates in J status: from to Page 6

ATTESTATION OF NO PATIENT CARE OR INCIDENTAL PATIENT CONTACT The University of Kansas Medical Center (KUMC) through its Responsible Officer, located in the Office of International Program has designation by the U.S. Department of State (DOS) Exchange Visitor Program to sponsor foreign nationals for the purpose of engaging in scholarly activity including research, teaching, consultation and observation. DOS regulations prohibit KUMC from sponsoring individuals who will be participating in patient care or clinical activity. As the supervisor responsible for the oversight of the exchange visitor, I affirm that the Visitor will not be involved in any element of patient care, even if said individual holds credentials that would otherwise permit such activity. (Note: If you are unable to sign this statement in good faith, exchange visitor sponsorship through KUMC is inappropriate for the individual or the situation, and you should contact the OIP to explore other options.) Supervisor Signature DEPARTMENT STATEMENT OF RESPONSIBILITY AS SPONSOR OF EXCHANGE VISITOR 1. As sponsor of the Visitor, I accept responsibility for the accuracy of all information contained in this form. 2. I will ensure the exchange visitor reports to the Office of International Programs no later than 3 days after arriving at KUMC, bearing the following documents for him/herself and all authorized dependents: Passport with I-94 Processed DS2019 Address of local residence (not KUMC) Phone / email or other contact information Proof of insurance as per U.S. Department of State regulations Per U.S. Department of State regulations, all Exchange Visitors and their dependents must carry health insurance to include medical evacuation and repatriation insurance. At the time of or prior to arrival in the United States, the Exchange Visitor should purchase the necessary insurance. The Office of International Programs will not check in an Exchange Visitor if they do not provide verification of insurance. Insurance must be maintained throughout the stay. Failure to maintain the required insurance may jeopardize the Exchange Visitor s status and their legal ability to complete their program in the department. 3. I understand that the Office of International Programs (OIP) cannot register the Visitor in the SEVIS system as present and in program status until the Visitor has reported to the OIP and has submitted complete documentation as listed above. Failure to be registered in SEVIS within 30 days of arrival will result in the Visitor s status defaulting to invalid. An individual with an invalid status is required to depart the United States, with no grace period. 4. I will notify the OIP within 3 days of any of the following events: Cancellation of plans for the Visitor to come to KUMC. All originals of the DS2019 will be returned to OIP Failure to arrive at KUMC by the start date noted on the DS2019 Intent to transfer to another KUMC department or host institution (Note: The new department must submit a Request for DS2019 for approval prior to transfer. A new/amended DS2019 will be issued if needed.) Termination of participation in activity at KUMC for any reason Supervisor Signature Department Head/Chair Signature Name Complete Title Page 7

DS-2019 REQUEST CHECKLIST Completed DS-2019 request forms with signatures for Attestation for English Proficiency Dependent Attestation (if applicable) Attestation for No Patient Care or Incidental Patient Contact Department Statement of Responsibility as Sponsor of Exchange Visitor Passport Identification Pages of J-1 Exchange Visitor Copies of degree certificates. If not in English, a certified translation should be included. Copy of offer letter or communication between sponsoring department and the individual confirming the appointment. Proof of funding: o Must meet minimum funding requirements of $18,620 for the J-1 (around $1551 per month); an additional $3,180 for each dependent. o If exchange visitor is funded through a scholarship, home government grant, or other institution, please attach evidence that shows amount and duration of support, and that the specified support is for the Exchange Visit to participate in a program at KUMC. Documents must be originals or copies of 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 a bank statement in English that shows available funds for the proposed exchange visit. If J-1 Exchange Visitor will be accompanied by J-2 dependents, include passport identification pages for each J-2 dependent. If J-1 Exchange Visitor ever held previous J status, please include copies of the following: DS-2019 documents Visa stamp I-94 Please submit a scanned copy of the DS-2019 request forms and supporting documents to both Alexandria Harkins and Irina Aris. Page 8