Compliance & Immigration Services
CONRAD STATE 30 WAIVER PACKET
For Foreign Physician Subject to the Two Year Home Residency Requirement (INA §212(e) Only)
(Revised: 09/2011)
THIS PACKET CONTAINS THE FOLLOWING FORMS:
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INTRODUCTION & CHECKLISTS...................................................................................................................................2
DEPARTMENT LETTER FOR CONRAD STATE 30 WAIVER .......................................................................................5
CONRAD STATE 30 LANGUAGE THAT MUST BE INCLUDED IN HSF CONTRACT .............................................7
SOM & DEPT. INVESTIGATION ATTESTATION .........................................................................................................8
J-1 PHYSICIAN ASSURANCES FORM .........................................................................................................................9
The Department is responsible for completing all forms titled “SOM Department” or “Department” and providing
the required supporting documents. The Employee is responsible for completing all Forms titled “Employee
Information” or “Employee Family” and providing the relevant supporting documents. Answer all questions, even
is the answer is ‘N/A’ or ‘None’. Incomplete packets will be returned to the department for full completion and
will not be considered as received until they are fully complete. Thank you for your cooperation in ensuring that
the filing process goes smoothly, by completing the forms in full and providing all documents requested.
Glossary of Abbreviations:
DHS – Department of Homeland Security
DOL – Department of Labor
USCIS – United States Citizenship & Immigration Services (a bureau of DHS)
HR-CIS – Compliance & Immigration Services (a division of UVa Human Resources)
When fully completed and signed by the Dean’s Office, the entire packet must be forwarded to Human Resources/Compliance and
Immigration Services (HRCIS).
If you have any questions about the Forms or the Checklists, please contact:
Compliance and Immigration Services, P.O. Box 400127
immigration@virginia.edu
(434) 243-2031
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INTRODUCTION & CHECKLISTS
PLEASE – NO STAPLES, WE HAVE TO REMOVE THEM AND IT ONLY SLOWS US DOWN!
All foreign physicians who enter the USA on a J-1 visa are subject to a two-year foreign residence requirement that requires the physician to
return to his or her country of last residence for a period of two years before being able to seek employment in the USA in H-1B status or
apply for US permanent residence. A few methods exist that allow the J-1 physician to have the two year requirement waived. One
method, being used by the University of Virginia, School of Medicine is the Conrad State 30 Waiver.
The Conrad State 30 Waiver process requires us to first request that the Virginia Dept. of Health (VDH ) sponsor the J-1 physician for a
waiver of the two year foreign residence requirement. In order to obtain the Conrad State 30 Waiver, the J-1 physician must agree to
employment with UVa for at least 3 years.
The VDH will review the application received and, if in support of the application, will request that the Department of State recommend the
J-1 physician for the waiver. Once the Dept. of State provides a letter of waiver recommendation, UVa will apply for H-1B status on behalf
of the J-1 physician.
The information above is a brief summary of the Conrad State 30 program. If additional information is desired, please contact HRCIS
CHECKLIST
1.
DEPARTMENT CHECKLIST:
Department Letter requesting Conrad State 30 Waiver. Original department letter – on letterhead -- addressed to
USCIS. Please see sample letter for direction.
HSF Employment contract WITH necessary Conrad State 30 language.
Department Medicaid and Medicare Provider Numbers
Evidence of all recruitment efforts in the past 6 months (advertisements, CV received, interviews held, results of
interviews)
SOM/Department Investigation Attestation (signed by Dean and Chair)
2.
PHYSICIAN CHECKLIST:
Copy of Dept of State Waiver Review Application and File Number Sheets. Application can be completed online at
https://j1visawaiverrecommendation.state.gov/.
All IAP-66 and DS-2019 forms issued
USMLE Scores – Steps 1, 2 and 3
ECFMG Certificate
Current Virginia Medical License
J-1 Physician Assurance Sheet (form is included in packet)
BC/BE documentation
Passport data page
Non-immigrant visa
Current I-94
All I-797 approval notices
At least three (3) letter of support with CV’s of letter writers. Letters should be addressed to Virginia Dept. of
Health.
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SERVICE REQUEST SHEET (Conrad State 30 Waiver)
Complete the information below and return with the completed application packet
ONLY INCLUDE FEES THAT WILL BE CHARGED TO THE PTAO.
Employee Name:
UVA Department:
UVA Dept. Contact Name & Phone Number:
UVA Dept. P.O. Box:
HRCIS Processing Fee:
$
HRCIS Expedited Service Fee:
$
TOTAL FEES DUE:
$
PTAO(s) To Be Charged:
Supervisor:
Name & Title
Signature
Date
Name & Title
Signature
Date
Department Chair:
H-1B FEES
SERVICE
USCIS FILING FEE(S)
HRCIS PROCESSING FEE
HR-CIS Conrad Waiver Processing Fee
$0.00
$2000.00
HR-CIS Expedited Service Fee
$0.00
$500.00
TOTAL FEE(S)
$2000.00
$500.00
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UVA DEPARTMENT – CONRAD WAIVER ATTESTATION
Please review the following, and sign below. Signatures are required by the department hiring officer, and an authorized
representative of the School of Medicine Dean’s office.
Date of Birth
(mm/dd/yyyy):
Employee Name:
The School/Department of:
certifies that:
1.
The School/Department wishes to sponsor the above-referenced individual for a Conrad State 30 Waiver as described in
this packet.
2.
The information provided in support of this request is true and accurate.
3.
The School/Department agrees to payment of the required fees for processing of the Conrad State 30 Waiver.
Certified by:
Name
Signature
Date
Direct Supervisor:
Department Chair:
Dean or HR Director:
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DEPARTMENT LETTER FOR CONRAD STATE 30 WAIVER
(PLACE ON LETTERHEAD AND REMOVE TITLE)
Date
Virginia Department of Health
Office of Health and Policy Planning
109 Governor Street, Suite 1016 East
Richmond, VA 23219
RE:
Conrad 30 J-1 Waiver Request [PHYSICIAN NAME]
Dear Sir/Madam:
The University of Virginia respectfully requests that its designated slot for the Conrad State 30 Waiver be
allocated for the employment of [PHYSICIAN NAME] as a [CLINICAL JOB TITLE] in the Department of [DEPT.
NAME] at the University of Virginia Health Systems.
The University of Virginia is located in Charlottesville, Virginia. The school is part of the University Virginia
Health System, an integrated network of primary and specialty care services ranging from wellness
programs and routine checkups to the most technologically advanced care. The hub of the Health System is a
hospital with over 500 beds in operation including a 110 bed Children’s Hospital. The University of Virginia
Health System provides care to all patients regardless of ability to pay (see attached).
The Department of [DEPT. NAME] and its clinics operating as part of its residency training program are the
primary source of medical care to under-insured and underserved populations for central and western
Virginia and parts of West Virginia, North Carolina and eastern Tennessee. In addition to the clinics at the
UVA Medical Center, clinics are operated in the Shenandoah Valley and the Roanoke area. The resulting
abundance of patient volume provides excellent opportunities for training. University interest in managed
care has ensured continued access to a large pool of potential patients.
[DISCUSSION ABOUT WORK OF THE DEPARTMENT, CLINICAL ACTIVITIES, CLINICS, OUTREACH ACTIVITIES,
ETC.]
Description of Unmet Need
According to the United States Department of Health and Human Services, Index of Medical Underservice
(IMU), Albemarle Virginia (Region III) is deficient in having specialized medical doctors. Patients are
referred from surrounding areas and states to the University of Virginia (UVA) Medical Center to receive
medical care.
Many patients who are referred to the UVA Medical Center come from rural areas that lack specialty c
physicians. As a teaching hospital, UVA strives to recruit and retain stellar physicians who practice in specific
medical specialty areas.
[DISCUSS THE UNMET NEED SPECIFIC TO THE DEPARTMENT OR DIVISION. EXTENT OF PATIENTS WITH
PROBLEMS THE DEPARTMENT/DIVISION ADDRESSES, MOST COMMON MEDICAL PROBLEMS IN THE AREA
SERVED]
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Recruitment Efforts
[DISCUSS DEPARTMENT’S RECRUITMENT EFFORTS: 1.WHEN RECRUITMENT BEGAN; WHERE
ADVERTISEMENTS WERE PLACED; WHAT RESPONSES WERE RECEIVED; WHETHER PEOPLE WERE
INTERVIEWED; WHETHER PEOPLE WITHDREW APPLICATIONS OR TURNED DOWN JOB OFFERS, ETC]
The Beneficiary
[DR ________] is an extraordinarily well-trained [STATE SPECIALTY]. [DISCUSS TRAINING, RESEARCH,
CLINICAL EXPERTISE OF FOREIGN PHYSICIAN]
Terms of Employment
We intend to employ Dr.[ __________] on a full time basis for a period of three years beginning [THREE
YEAR PERIOD OF EMPLOYMENT]. He will be compensated at a salary of $[SALARY] per year (see attached
offer letter and contract). He will work between 40-60 hours per week over 5 days. His time will be
divided into two days in the clinic, one day in the operating room, one day in the laboratory, and one day
as Residency Program Director [ALTER DIVISION OF TIME AS NECESSARY REMEMBERING THAT THE WAIVER
IS FOR POSITIONS REQUIRING A LARGE AMOUNT OF CLINICAL RELATED DUTIES]. Dr. [_________] will
practice inpatient and outpatient [AREA OF CLINICAL CARE] at the University of Virginia Department [DEPT.
NAME] located at [ADDRESS OF CLINIC], Charlottesville VA 22908.
If you have any further questions, please do not hesitate to contact the University’s Compliance & Immigration
Services at (434) 243-2031.
Respectfully,
___________________________
[NAME OF CHAIR]
Professor and Chair
Department of [DEPT NAME]
___________________________
[SOM DEAN]
Dean of the School of Medicine and Vice-President
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CONRAD STATE 30 LANGUAGE THAT MUST BE INCLUDED IN UVa. Physicians Group CONTRACT
PLEASE ENSURE THAT THE UVa. Physicians Group EMPLOYMENT CONTRACT INCLUDES THE FOLLOWING
LANGUAGE. THE NECESSARY ADDITIONS ARE IN RED INK.
1.
EMPLOYMENT. The Clinician is employed pursuant to the terms of this Agreement to practice the profession for which
the Clinician is licensed. Notwithstanding such employment, the professional relationship between the Clinician and the
patient shall remain inviolate, including, without limitation, the Clinician's determination of the appropriate healthcare
to be rendered the patient, the personal liability, if any, of the Clinician with respect to the rendition of such care,
and the confidential relationship between the Clinician and the patient. The Clinician agrees to full-time employment
of at least 40 hours per week, but at no time shall the Clinician work more than 40 hours in any four day period.
Further, The Clinician agrees to the Clinician’s duties as a faculty member of the School of Medicine of the University
of Virginia in Charlottesville, in a manner determined by the Clinician's Department Head and Dean, and not
inconsistent or in conflict with the practice of the Clinician's profession on behalf of the UVa. Physicians Group..
2.
CONRAD 30 WAIVER. The Clinician is aware that the University of Virginia, School of Medicine is fully assisting with
a request for a Conrad State 30 Waiver for a waiver of the 2-year foreign residence requirement of her J-1 visa.
Pursuant to this, and in accordance with the Immigration & Nationality Act, Section(s) 214(l)(1)(A), (B, (C) the Clinician
states the following:
a.
That a Conrad State 30 Waiver has been filed, on the Clinician’s behalf, by the University of Virginia, School of
Medicine, with the Virginia Department of Health;
b.
That the Clinician has no contractual obligation to return to a home country. However if such contractual obligation is
found to exist, the Clinician will request and obtain a ‘no objection’ letter from the Clinician’s home government
wherein it will be stated that the home country has no objection to the Conrad State 30 Waiver. The Clinician will
ensure that the home government directly furnish the Department of State with the ‘no objection’ letter, as necessary;
c.
That the Virginia Department of Health is an interested State agency requesting a waiver under the Conrad State 30
Waiver program in order to allow the Clinician to serve as a [Clinical Job Title] with the University of Virginia
Physicians Group and the University of Virginia School of Medicine;
d.
That this Standard Employment Contract demonstrates a bona fide offer of full-time employment has been extended
to the Clinician by a health facility;
e.
That the Clinician will begin employment with the University of Virginia Physicians Group and University of Virginia
School of Medicine within 90 days of receiving the J-1 waiver and agrees to continue to work for a total of not less
than three (3) years absent extenuating circumstances, as outlined by Section 214(l)(1)(C)(ii).
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SOM & DEPT. INVESTIGATION ATTESTATION
University of Virginia School of Medicine
Investigation Attestation
To the best of my knowledge, I attest that the University of Virginia’s Department of
__________________________, is not under investigation, indictment or conviction for
violations of federal, state, or local laws, regulations, or ordinances related to the medical
practice.
In addition, to the best of my knowledge, the Department of ________________ is not the
subject of any financial, legal or regulatory proceedings that could reasonably result in an
inability to function as an employer.
UNIVERSITY OF VIRGINIA
SCHOOL OF MEDICINE
_________________________________________
[DEAN]
Dean and Vice President
_____________________________
[DEPT. CHAIR]
Professor and Chair
Department of [DEPT NAME]
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J-1 PHYSICIAN ASSURANCES FORM
(TO BE COMPLETED BY J-1 PHYSICIAN ONLY)
Attachment 3
VIRGINIA STATE-30 J-1 VISA WAIVER PROGRAM
J-1 PHYSICIAN ASSURANCES
I __________________________________________________________(Name)
hereby declare and certify, under penalty of the provisions of 18 U.S.C. 1101, that I do not now have pending
nor am I submitting during the pendency of this request, another request to any United States Government
department or agency or any state department of public health, or equivalent, other than the Virginia
Department of Health, to act on my behalf in any matter relating to a waiver of my two-year home-country
physical presence requirement.
I further declare and certify that I have no contractual obligation to return to my home country. (If such a
contractual obligation exists, the J-1 Physician must obtain a letter of “no objection” from the home country or the
embassy in Washington, D.C.)
I agree to accept assignment under Section 1842 (b)(3)(ii) of the Social Security Act as full payment for all
services for which payment may be made under Part B of Title XVII of such Act (Medicare).
I agree to obtain a medical provider number from the Virginia Department of Medical Assistance Services and
sign a contract to provide services to persons entitled to medical assistance under Title XIX of the Social Security
Act (Medicaid).
I agree to provide to the Virginia Department of Health a completed Verification of Employment Form (attached)
within 30 days after my employment begins, and every six months thereafter, until my three-year commitment is
completed. I understand that failure to submit this report accurately and completely will result in a report of noncompliance to the U.S. Immigration and Naturalization Service.
___________________________________________
Signature
___________________________________________
Name (Print or Type)
______________________
Date
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