Export Controls Questionnaire
Complete this form to request a review of the technology and information to which an invited international visa holder may have access while
working at UT Southwestern. Both the prospective visa holder and the technology and information to be made available to the visa holder must
be approved by the university’s Compliance Officer to determine whether or not an export controls license is required. If it is determined that
an export license is required, no access to controlled technology, technical data or information by the prospective visa holder may be permitted
until the export controls license is received.
Please include the original, completed questionnaire with the rest of the visa application materials to be delivered to the Office of International
Affairs, NL 3.252. Please visit the Export Controls website for additional information:
http://www.utsouthwestern.net/intranet/research/research-administration/export-controls/.
I.
INFORMATION ABOUT PROSPECTIVE VISA HOLDER
Name of Prospective Visa Holder Exactly as it Appears in Passport:
Family Name:
Date of Birth:
Given Name:
______ ______ ______
(Day) (Month) (Year)
City and Country of Birth:
Country of Citizenship:
II.
Passport Number:
HOME COUNTRY ADDRESS
Street and Number:
City:
Province:
III.
Postal Code:
Country:
ADDRESS IN UNITED STATES IF ANY
Street and Number:
State:
IV.
Middle Name(s)
City:
Zip Code:
INFORMATION ABOUT INSTITUTION IN HOME COUNTRY
Name of Home Country Institution: ___________________________________________________________________
Name of Immediate Supervisor at Home Country Institution: ______________________________________________
V.
INFORMATION FROM SPONSORING DEPARTMENT
Name of Principal Investigator/Supervisor:
Primary Departmental Affiliation:
Mail Code:
Last updated on 1/30/2014
Campus Phone Number:
UT Southwestern Title:
FUNDAMENTAL RESEARCH
Generally, most research conducted at UT Southwestern is excluded from export control rules because of the fundamental
research exemption. However, under certain circumstances, these fundamental research exemptions may be lost or do not
apply. Fundamental research is defined as basic and applied research in science and engineering, the results of which
ordinarily are published and shared broadly within the scientific community, as distinguished from proprietary research and
from industrial development, design, production and project utilization, the results of which ordinarily are restricted for
proprietary or national security reasons.
VI.
INFORMATION ON THE RESEARCH PROJECT UNDER WHICH THE VISA HOLDER WILL BE WORKING:
a. Does the research statement of work or any language in the agreement give the sponsor the right to
approve/disapprove publication (excluding reasonable reviews for possible patents and/or sponsor proprietary
information)?
Yes_______
No ______
b. Does the research statement of work or any language in the agreement reference U.S. export regulations or security
restrictions (beyond a mere statement to comply with the law)?
Yes_______
No ______
c.
Does the research statement of work or any language in the agreement prohibit the involvement of non-U.S.
persons or persons from certain countries or require prior approval from the sponsor?
Yes_______
No ______
d. Does the research statement of work or any language in the agreement require UTSW to identify foreign nationals
including their citizenship?
Yes_______
No ______
e.
Does the research statement of work or any language in the agreement prohibit access to projects
materials/data/information by non-U.S. citizens?
Yes_______
No ______
f.
Does the research statement of work or any language in the agreement allow the sponsor to claim resulting
information as proprietary or trade secrets?
Yes_______
No ______
g.
Does the research statement of work or any language in the agreement restrict the dissemination of research
results?
Yes_______
No ______
h. Does the research statement of work or any language in the agreement indicate the project has an obvious military
nature?
Yes_______
No ______
*If yes to any of the above, the fundamental research exclusion may be lost and an export control issue may exist.
Contact Export Controls Officer for further review.
i.
Does this project involve a foreign sponsor, foreign collaborators and/or travel outside of the U.S.?
Yes_______
No ______
If yes, name the country of sponsor, collaborator or travel destination: _____________________________________
_________________________________________________________________________________________________
Last updated on 1/30/2014
DUAL-USE RESEARCH
In the life sciences, dual-use research “encompasses biological research with legitimate scientific purpose, the results
of which may be misused to pose a biologic threat to public health and/or national security.” Generally, the term tends
to refer to technologies that have both a civilian and a military use. The dual-use research dilemma in the life sciences
refers to the conundrum of producing and publishing research within the life sciences that is directed toward or
intended to improve public health, animal health or agricultural productivity, but, in the hands of a rogue state,
terrorist group or individual, could be used to impair public health.
VII.
RESEARCH ENVIRONMENT
a. Will the Visa Holder be working with one or more of the Select Agents or Toxins found on the Health and Human
Services or Food and Drug Administrations’ list?
http://www.selectagents.gov/Select%20Agents%20and%20Toxins%20List.html
Yes_______
No ______
b. Can any equipment or materials used in conjunction with the research project be considered to be of “dual-use”?
Yes_______
VIII.
No ______
Please provide a one paragraph description of the work to be performed, and the “controlled” technology and/or
information, if any, to which the prospective visa holder will have access at UT Southwestern:
IX.
SIGNATURES:
Signature of Principal Investigator/Supervisor:
Signature of Department Chair or Center Director:
Printed Name of Department Chair or Center Director:
Last updated on 1/30/2014
_______________
Date: ____ ____ ____
Date: ____ ____ ____