Services for International Students and Scholars (SISS)
UNIVERSITY OF CALIFORNIA, DAVIS, One Shields Ave., Davis, CA 95616-8698
Phone: (530) 752-0864
Fax: (530) 752-5822
E-mail: siss@ucdavis.edu
REQUEST FOR EXTENSION OF
EXCHANGE VISITOR (J-1) STATUS
(rev. 6/2015)
Return this request to SISS at least 30 days before the expiration date on the current DS-2019 form.
1. Typed Request for Form DS-2019
2. Health Insurance Memo of Understanding
3. Documentation of Funding
 Funding may come from UC Davis, a non-UC source, or a combination
 For Postdoc titles, wage must meet Union wage requirements, regardless of
source.
 For Undergraduate Researchers/Non-degree students, only 50% of funds may
come from personal funds; 50% must come from UC Davis or other sources
4. Appointment or Invitation Letter from Host Faculty Member
 For Postdocs, attach a copy of the Postdoc contract (no letter needed)
 For all other employees, include detailed appointment letter (go to link for a
template employment letter)
 For non-employees, invitation letter has to include information listed in Sec.
A.5.
5. Attachment for J-1 Physician (See Sec. A.6.) if applicable
Please Keep in Mind the Time Limits for Each J Category:
Short-term Scholar
Specialist
Undergraduate Researcher
Research Scholar/Professor
6 months
12 months
24 months
5 years
Save paper! This page is meant to assist departments and does not need to be included in the DS-2019
request packet submitted to SISS.
Rev. 6/18/2015
Part A: To be completed by the University of California, Davis or UCDMC Department (Please type)
1.
Name:
2.
Date J-1 status first obtained:
3.
Expiration date of current Form DS-2019 (shown in section #3 of the DS-2019):
4.
5.
UC Davis position title:
title code:
NO UCD position title code:
Attach a letter written on official letterhead from host faculty member with non-technical description of proposed activity, work
location, salary, benefits, and dates. If postdoc, it is only necessary to include a copy of the postdoc contract.
6.
If scholar has M.D. degree, complete Attachment for J-1 Physician
7.
Period of extension for which funding is guaranteed:
family/last
8.
8.
Name of Department:
9.
Current J-1 Category:
given/first
middle
Date of Birth
from:
to:
mm/dd/yyyy
mm/dd/yyyy
Has there been a change in UCD departments for
this request? Yes
9.
Research Scholar
Short-term Scholar
Specialist
No
Undergraduate Researcher
10. FINANCIAL SUPPORT
Indicate financial support below. The required minimum support for scholars and their families is $2,000.00 per month for the
scholar, $600.00 per month for a spouse and $300.00 per month for each child. This does not include airfare, health insurance or
child care expenses.
Letter b) below refers only to funds granted directly to the scholar for the specific purpose of supporting participation in the
Exchange Visitor Program. Salary from funds granted to UCD to support research projects should be listed under letter a)
for UCD payroll. Please include funding information for the ENTIRE extension period listed in #7 above.
…………………………………………
Amount:
$
………………………………………………………………
Amount:
$
c.
Exchange Visitor’s Government: ……………………………………………………………
Amount:
$
d.
Other (specify):
………………………………………………………………………….
Amount:
$
e.
Personal Funds: ………………………………………………………………………………
Amount:
$
Total funding for the initial visit period: ……………………………………………………..
Amount:
$
a.
UCD (specify payroll, honorarium, per diem):
b.
U.S. Government Agency:
Written verification (in English and U.S. dollars) is required for financial support not provided by UCD.
11. HEALTH INSURANCE: The Exchange Visitor and his/her accompanying dependents must have health insurance coverage as
specified by the Department of State program regulations (See Section B.3)
12. A departmental recharge is authorized for SISS services to support the above-named international professor or researcher. This
fee can be paid only on a department recharge basis and cannot be paid directly by the scholar. Reimbursement for this recharge
may be available through your dean’s office. This recharge does not include visa renewal fees at the U.S. consulate or USCIS
processing fees.
Recharge fee of $415 will be charged to:
(Lower case letters, please)
COA
DaFIS account number (seven digit)
DaFIS sub account number (five digit)
Our signatures confirm agreement with the above points.
Host/Supervising Faculty Member
Signature
E-mail address
Phone #
Date
Department Chair
Signature
E-mail address
Phone #
Date
Department Administrative Contact
Signature
E-mail address
Phone #
Date
Print Name
(UCDSOM Appointments ONLY)
Dean’s Signature
Date
Rev. 6/18/2015
Part B. All questions to be completed by scholar and returned to inviting UCD department.
Scholar Information
Street
Apt. #
City
State
E-mail:
Do you plan to travel outside the U.S. within the
Department Phone:
next 6 months?
*If yes, please complete the travel information below.
Zip Code
Home Phone:
Yes*
No
Yes*
No
Travel Information
Do you plan to travel outside the U.S. before the expiration date on your current
2019?
*If yes, what is the expected
date of departure?
DS-
*Will you apply for a new visa during this
trip:
Have you ever applied for a waiver of 212(e) (two year home residence requirement)?
Visa Expiration Date:
Travel Destination:
Yes
No
Yes
No
Passport Expiration Date
Departure Date:
Return Date:

I understand that I will need to have a valid J-1or J-2 visa in my passport to re-enter the USA.

I certify that the above information is true and correct. I verify that my intention is to return to the United States to
continue my Exchange Visitor program on or about the date listed above.
Signature of Exchange Visitor: ____________________________________________ Date: ______________
J-2 Dependent Information
Please provide the following information for the dependents in J-2 status that are in the U.S. with you (if you need more lines, you may
insert more rows into the table):
NAME OF FAMILY
MEMBER
(Family/Last,
First/given, middle)
RELATIONSHIP
(spouse,
daughter, son)
DATE OF BIRTH
(mm/dd/yyyy)
CITY OF BIRTH
COUNTRY OF
BIRTH
COUNTRY OF
CITIZENSHIP
COUNTRY OF
PERM.
RESIDENCE
J-2 spouse’s e-mail address (if applicable):
Rev. 6/18/2015
International Scholar Health Insurance Memo of Understanding
By signing this document, the scholar named below confirms his/her understanding of the medical insurance
requirements listed here:
1. I understand that the Department of State requires all J-1 Exchange Visitors and their accompanying
dependents to have health and accident insurance coverage that must begin no later than the “Program
Begin Date” as noted on the DS-2019 form and must not end before the effective “Program End Date.”
2. I understand that if I am full-time employed or have the title of “postdoc” at UC Davis, I must check with
my department to find out if I will be offered health insurance through UC Davis or if I must buy it
independently. (In most cases, postdoc titles and other full-time employment at UC Davis will include health
benefits. Scholars must talk to their departments.)
3. I will maintain health benefits for myself and any J-2 dependents at minimum at the amounts listed below:
 - -Medical benefits per accident or illness of at least: $100,000 minimum*
 - -Repatriation of Remains:$25,000
 - -Expenses related to Medical Evacuation: $50,000
 - -Deductible per accident or illness not to exceed $500
*Please note: SISS considers the minimum medical coverage per accident or illness required by law to be low for
the cost of medical care in today’s medical system. Therefore, we recommend that international scholars
purchase health care benefits at a minimum of $250,000.00 per accident or illness. Insurance policies may require
a waiting period for pre-existing conditions and provisions for co-insurance under which the J-1/J-2 may have to
pay up to 25% of covered benefits per accident or illness.
4. The insurance corporation underwriting the policy must have one of the following ratings. Note: Insurance
coverage backed by the full faith and credit of your home government meets these requirements:





- -an A.M. Best rating of “A-” or above
- -a McGraw Hill Financial/Standard & Poor’s Claims-paying Ability rating of “A-” or above
- -a Weiss Research, Inc. rating of “B+” or above
- -a Fitch Ratings, Inc. of ‘A-“ or above
- -a Moody’s Investor Services rating of “A3” or above
Insurance information can be found on the SISS website at http://siss.ucdavis.edu/health_j1.cfm. Please
review this website for some US health insurance company options. Note that you and your J-2 dependents
may also be subject to the requirements of the Affordable Care Act (ACA). SISS recommends that J-1 scholars
purchase travel insurance coverage for the first month in the US, to provide health coverage until a longer-term
health insurance plan is selected and purchased for the J-1 program duration.
_____________________________________________________________________________________
Scholar Declaration: I understand that I am responsible for the purchase of health insurance that meets the
above requirements. I understand the cost of insurance premiums (monthly payments) in the US is high and I
confirm that I will have sufficient finances to cover the cost of insurance premiums throughout my stay. I
understand that U.S. government regulations require the University to notify the U.S. Department of State and
to terminate my J-1 exchange visitor status if they determine that my family members or I willfully failed to
comply with the insurance requirements.
Name:
family (last)
Signature:
given (first)
middle
Date
Rev. 6/18/2015
Attachment to Request for Extension Form for J-1 Physicians
Section I or II below is to be completed by the J-1 physician's host department chair and supervisor and is to
accurately reflect the type of patient contact that the physician will have. This form should be given to the J-1
physician for signature on Section III. Please attach this completed form to the Request for Extension and return it
to SISS.
I.
If the J-1 physician is coming to UCD to pursue a program that does not involve patient contact, the
applicant's UCD sponsor must certify the following:
This certifies that the program in which Dr
is to be engaged is solely for the purpose of
observation, consultation, teaching, or research and that no element of patient care services is involved.
Print or type name of Department
Chair
Signature of Department
Chair
Print or type name of Faculty
Sponsor
Signature of Faculty
Sponsor
Date
Date
II. If incidental patient contact is involved in the J-1 physician's duties, the UCD sponsor must certify the following
five points:
1. The program in which Dr.
will participate is predominantly involved with observation,
consultation, teaching, or research.
2. Any incidental patient contact involving the J-1 physician will be under the direct supervision of a
physician who is a U.S. citizen or resident alien and who is licensed to practice medicine in the state of
California.
3. The J-1 physician will not be given final responsibility for the diagnosis and treatment of patients.
4. Any activities of the J-1 physician will conform fully with state licensing requirements and regulations
for medical and health care professionals in the state of California.
5. Any experience gained in this program will not be creditable toward any clinical requirements for
medical specialty board certification.
Print or type name of Department
Chair
Signature of Department
Chair
Print or type name of Faculty
Sponsor
Signature of Faculty
Sponsor
Date
Date
III. To be completed by prospective J-1 Physician:
I understand and agree with the above statement(s) regarding the level of patient contact I will have during
my proposed activity at UC Davis.
Print or type name
Signature of Prospective J-1
Physician
Date
If the J-1 physician's program involves significant patient contact or otherwise does not conform with Section I or II
above, the physician cannot be sponsored through the UCD J-1 Exchange Visitor Program.
Clinical training for J-1 physicians who are interns, residents or who hold other clinical positions involving patient
contact can be authorized under a program sponsored by the Educational Commission for Foreign Medical
Graduates (ECFMG). For further information regarding ECFMG sponsorship, contact the School of Medicine
Office of the Dean: http://www.ucdmc.ucdavis.edu/dean/contactus/
Rev. 6/18/2015