International Student and Scholar Services
J1 Exchange Visitor - Intern
Department Request Form
Stevens Institute of Technology (Stevens) is currently authorized to invite students to participate in a student internship
program that meets the students’ home institutions educational requirements. This form must be completed by the
sponsoring department, and the appointment of the student intern must be approved by the head of the department. To
avoid delays in the J-1 Student Intern application process, the application package must be completed and submitted in its
entirety. ISSS requires a minimum of two week to evaluate and process a J-1 Exchange Visitor (EV) application.
Department Name_________________________________________________________________________
Department Administrator Name:________________ Email_____________________ Phone_____________
Faculty Sponsor Name: _____________________________________________________________________
Faculty Sponsor Title: ______________________________________________________________________
Faculty Sponsor Email _____________________ Faculty Sponsor Phone: _________________
Student Intern’s Last Name: __________________
Length of proposed stay:
Student Intern’s First Name: ___________________
From:_______________
Month/date/ year
To: __________________
month/date/ year
Source of financial support for the duration of the program (minimum $1,750 per month)
Student will be funded (or partially funded) by Stevens:
___ Yes: Monthly stipend: $ __________
___ No: Student must provide personal financial support documentation (please see financial information sheet)
Student will be eligible for Stevens’ Health Insurance Plan:
___ Yes
___ No: Student must provide proof of health insurance upon arrival (please see health insurance requirement sheet)
Specific field of proposed internship activity (i.e. Chemical Engineering, Info System, etc.): _____________________
Departmental Acknowledgement and Consent:
Please read the following internship activity guidelines and requirements. By signing the Program Content Guideline form
below, the supervising faculty member and the dean of the college confirm that the proposed internship participation for the
aforementioned undergraduate student meets the regulatory activity requirements.
Program Content Guidelines (22 C.F.R. § 62.23)
___ the internship participation may not exceed 12 months
___ the internship participation must consists of a minimum of 32 hours per week
___ the internship participation must consist of no more than 20% clerical work
___ all tasks assigned must be for the purpose of completing the internship program
___ the internship participation cannot be used to displace American workers and/or fulfill a labor need
___ the internship participation consists of work based learning, rather than simple employment
___ the internship participation is to expose the participant to "American techniques, methodologies, and technology,"
expand upon the participant's existing knowledge and skills, and "not duplicate the student intern's prior experience."
___ the internship participation may not include any clinical work and/or patient care
Program Facilitation Guidelines
___ I will notify ISSS if the exchange visitor will not be able to arrive by the program start date listed on the Form DS-2019
___ I will notify ISSS if the exchange visitor will not be participating in this program
___ I will notify ISSS if the exchange visitor completes his/her program participation before the scheduled end of the
program as stated on the Form DS-2019 and will submit the J-1 Exchange Visitor Early Departure Form
___ I understand that the Exchange Visitor must consult with ISSS prior to agreeing on any changes to his original agreement
(i.e. changes in research activity, funding, etc)
___ I understand that: 1) the exchange visitor must check in with ISSS upon arrival in the U.S. and no later than 10 days after
the program start date stated on the Form DS-2019, 2) I am responsible for ensuring that the exchange visitor reports to ISSS,
and 3) that the exchange visitor’s failure to report to ISSS may result in the termination of his/her exchange visitor program
participation at Stevens.
___ I will perform a final evaluation with the student intern upon completion of the internship and submit the evaluation to
ISSS. (For program’s lasting longer than six months, a midterm evaluation is required at that time). As per federal
regulations, a final evaluation is required, and it must be retained for a period of three years after completion of the
program.
Faculty Supervisor
Printed Name___________________________
Signature_____________________Date______
Head of Department
Printed Name___________________________
Signature_____________________Date______