University of South Florida
College and Department Deemed Export Questionnaire
Instructions: On 11/23/10, the USCIS released a revised I-129 application form (used in the H1-B and O-1 petition process) that includes the
requirement for an export certification for each foreign national employee. This form is intended to provide the USF Office of Export Control
with information necessary to start the assessment process. It should be completed by the employee’s supervisor and signed by the
Department Chair. The form is sent to the USF Export Control Officer. It will be returned to the submitting department and should then be
sent to the International Services Office with the G-28. No university petition for H1-B or O-1 can be submitted unless this process is
completed.
Section A: Employee Information
Employee Name: ________________________
Current Visa Type/Status: _______________________________
Country of Birth: ________________________
Country of Citizenship: __________________________________
Sponsoring Dept.: _______________________
Supervisor Name: ______________________________________
List all University accounts used to support the employee’s salary, and if applicable, their research:
Section B: Position Information
Will the employee have access to technology (software, equipment or material(s) specifically designed or developed for military (e.g. night vision, GPS Y-code,
shielding, UAVs or targeting algorithms) or space (e.g. rockets, missiles, satellites, space telescopes or probes) applications?  Yes  No  Not sure If yes,
provide a list of the military or space applications below.
Will the employee be provided access to USF, sponsor or third party export controlled, confidential or proprietary information, software or technical data? This
would include information about the design, manufacture or repair of standard laboratory equipment that is not in the public domain; it does not include basic
operation or use instructions.  Yes  No  Not sure If yes, provide a brief description below.
Will the employee be involved in any research or other scholarly activity that is not intended for public dissemination?  Yes  No  Not sure If yes, please
provide the proposal number, contract number, and sponsor below.
Will the employee be provided access to any ongoing DoD, NASA or defense industry research or research results?
Will the employee be involved in any scientific, technical, or engineering research project?
 Yes  No  Not sure
 Yes  No  Not sure
If yes, please provide the following:
Title of project:
Project Identification number:
Funding agency:
A brief and lay description of the research and how results will be shared
If yes or if comments have been made in any question, please forward to The Office of Export Control for review at exportcontrol@usf.edu.
If you check, all no’s send the form directly to Marcia Taylor at CGS101.
The person signing this is attesting that they have full knowledge of the scope of the research work of the employee:
_________________________
Signature of USF Supervisor
_____________________
Print Name
_____________________
Date
__________________________
Signature of USF Department Chair
_____________________
Print Name
_____________________
Date
University of South Florida Export Control
Side 1
Section C - CERTIFICATION
To be completed by USF Export Control Officer
Export Control, administered by the Division of Sponsored Research (DSR), at the University of South Florida, has
reviewed the attestations above. After review of associated agreements and the information provided by the
sponsoring department, Export Control has determined that, as of the date signed:
A license is required from the U.S. Department of Commerce and/or the U.S. Department of
State to release such technology or technical data to the beneficiary and the petitioner will prevent
access to the controlled technology or technical data by the beneficiary until and unless the petitioner
has received the required license or other authorization to release it to the employee.
The University has received the required license or other authorization to release information to the employee
A license is not required from either U.S. Department of Commerce or the U.S. Department of
State to release such technology or technical data to the employee.
_____________________________
Signature of Export Control Officer
University of South Florida Export Control
____________________
Printed Name
______________
Date
Side 2