DS-2019 Departmental Request Form

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Request for Issuance of Form DS-2019
For Use by Departments at
East Tennessee State University
When an ETSU department has invited an international scholar(s) for a visit, the J-1 visa is often the most
appropriate for the visitor. This form should be completed by the host department (not by the visitor),
signed by the department head, and sent to: International Programs and Services, Box 70668.
The Director will then issue a Form DS-2019 that the scholar should use to get a J-1 visa to enter the
U.S. This request form should not be used for students. If you have any questions, please call the
International Programs and Services at 439-7737.
Part I – Department Information
Host Department:
Department Address: Street:
City:
State:
Phone:
Zip/Postal Code:
Fax:
Host Professor/Staff Member:
Phone:
E-mail:
----------------------------------------------------------------------------------------------------------------------------------------Part II – Scholar Information
Name of Scholar Last:
Male:
Female:
Place of Birth City:
First:
Middle:
Date of Birth (mm/dd/yyyy):
Country:
Country of Citizenship:
Country of Legal Permanent Residence:
Occupation and Employer in Country of Permanent Residence
Occupation:
Employer:
Highest Degree Received (check one)
Ph.D.
Other:
If not Ph.D., give date and actual name of degree (not U.S. equivalent):
See the English Language Proficiency Policy on the International Programs and Services Forms
webpage under J-1 Scholars heading.
How will the prospective visiting scholars document his or her English Proficiency level?
____TOEFL – scores must be submitted to ETSU electronically.
____Oral Proficiency Interview (OPI) test – if this is the option, please contact Dr. Martha Michieka
January 2015
([email protected]) to make an appointment for the interview via WebEx. Dr. Michieka will provide
International Programs and Services with the OPI report.
Has this scholar held J-1 immigration status in the past 12 months?
Yes:
No:
If yes, give dates and locations of most recent visit:
(If scholar is currently in the U.S., attach copies of all previous IAP-66 and DS-2019 forms.)
Will the scholar be accompanied by spouse or children? Yes:
No:
If yes, give names, dates of birth, places of birth, and relationship to scholar on a separate page.
Visitors Mailing Address:
Street:
City:
State:
Country:
Zip/Postal Code:
Telephone Number:
Fax Number (if available):
E-mail Address:
Check One:
International Programs and Services should mail DS-2019 by regular mail.
Host Department will mail DS-2019: please call when ready for pick-up.
Mail by Express Courier; charge to Host Department account number:
---------------------------------------------------------------------------------------------------------------------------------------Part III – Program Information
Description of Scholar’s Proposed Program at ETSU (Examples: conduct research in theoretical physics;
teach courses in Italian; conduct three-day workshop in ecology; observe university administration, etc.)
Dates of visit at ETSU (mm/dd/yyyy)
From
To
PLEASE NOTE: It is the responsibility of the visiting scholar’s faculty/staff host to notify
International Programs and Services if the exchange visitor is not able to enter the United State by
the program date noted above. The visitor’s SEVIS record MUST be promptly updated in such
circumstances. An exchange visitor may not enter the United States after program beginning
date has passed. If you have any questions, please call 9-7737.
Proposed job title at ETSU, if applicable (J-1 Visa may not be used for tenure-track positions)
Will scholar be employed by or visiting other U.S. institutions before or after ETSU visit?
Yes:
No:
If yes, give details on a separate sheet or call the International Programs and Services office to discuss.
(Visitor is permitted to live in U.S. for up to 30 days as travel after leaving ETSU without special
January 2015
permission. Employment is permitted during this period.)
Is there a possibility that the scholar will extend his/her stay beyond the dates given above?
Yes:
No:
If yes, will scholar stay longer than six months?
Yes:
No:
Or longer than three years? Yes:
No:
Explain:
----------------------------------------------------------------------------------------------------------------------------- ----------Part IV – Funding Information
List all sources of support to scholar during visit. Please document all non-ETSU financial
support.
Source
Host Department at ETSU
Visitor’s Government (submit documentation)
Personal funds
Other – Specify:
Amount
Please Note: Exchange Visitors under the J-1 status are not eligible for any type of U.S. government aid
such as food stamps, free health care, free school lunches, subsidized housing, etc. Acceptance of such
aid is a violation of the J-1 regulations.
ETSU Will
or Will Not
pay scholar with funds obtained specifically for this Scholar or for
international exchange. If yes, provide explanation or copies of relevant contracts or correspondences
(this does not apply to research funds).
Facilities and services the department will provide for scholar (Examples: office, telephone,
secretarial help, free housing, hotel accommodations paid for, etc.):
_________________________________________________________________________________
Part V – Export Control Regulations
An export occurs when a controlled physical item or controlled information is transmitted outside the
United States borders or when a controlled physical item or controlled information is transmitted to a
foreign person in the United States. The term “export” includes: (1) actual shipment of any controlled
physical items; (2) the electronic or digital transmission of any controlled information; (3) any release or
disclosure, including verbal disclosures and visual inspections, of any controlled information; or (4) actual
use or application of controlled physical items or controlled information on behalf of or for the benefit of a
foreign entity or person anywhere. Additional information is available
Is there a possibility that the scholar will be involved in research activities which may have implications
under federal export control regulations?
Yes:
No: _I do not know: _
If yes, review and approval from ETSU’s Regulatory Compliance Officer is mandatory. If you have any
January 2015
question, please call the Office of Research and Sponsored Programs Administration at 439-6052.
----------------------------------------------------------------------------------------------------------------------------- ----------Part VI – Health Insurance Information
Host Department
Will
or Will Not
pay for health insurance for the visitor.
Please Note: All J-1 visiting scholars and their dependents MUST have health insurance in accordance
to the
Please Note: Federal Regulations make health insurance coverage mandatory for all exchange visitors
under the J-1 status throughout their stay in the United States.
Approved by Host Department Head:
Signature:
Name:
Date:
January 2015
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