J-1 EXCHANGE VISITOR PROGRAM AT KUMC DEPARTMENT REQUEST FOR A DS-2019 EXTENSION

Office of International Programs University of Kansas Medical Center 3901 Rainbow Blvd., Mail Stop 3033 5010 Wescoe Kansas City, KS 66160 Phone: 913-588-1480 Fax: 913-588-1462 Mail Stop 3033, 3901 Rainbow Blvd., Kansas City, KS 66160 J-1 EXCHANGE VISITOR PROGRAM AT KUMC DEPARTMENT REQUEST FOR A DS-2019 EXTENSION OFFICE OF INTERNATIONAL PROGRAMS (OIP) CONTACT INFORMATION Alexandria Harkins International Advisor and Program Facilitator, ARO, DSO Email: aharkins2@kumc.edu Phone: 913-588-1460 Irina Aris Assistant Director of Inbound Programs, RO, DSO Email: iaris@kumc.edu Phone: 913-588-1485 DS-2019 EXTENSION REQUEST CHECKLIST COMPLETED AND SIGNED DS-2019 EXTENSION REQUEST FORM SUBMIT A SCANNED COPY OF THE REQUEST FORM AND ANY SUPPORTING DOCUMENTS BY EMAIL TO BOTH ALEXANDRIA HARKINS (aharkins2@kumc.edu) AND IRINA ARIS (iaris@kumc.edu). PART1: SPONSORING DEPARTMENT INFORMATION SPONSORING DEPARTMENT NAME: SPONSORING DEPARTMENT PHYSICAL ADDRESS (LOCATION OF THE ACTIVITY ON CAMPUS): 3901 RAINBOW BLVD. KANSAS CITY, KS 66160 o LOCATION ON CAMPUS: SPONSORING SUPERVISOR DEPARTMENT CONTACT/ ADMINISTRATOR OTHER: NAME: TITLE: PHONE NUMBER: EMAIL ADDRESS: NAME: TITLE: PHONE NUMBER: EMAIL ADDRESS: IF ACTIVITY WILL TAKE PLACE AT THE VA MEDICAL CENTER, PLEASE COMPLETE THE FOLLOWING: Is the sponsoring supervisor affiliated with the University of Kansas Medical Center? PART 2: J-1 EXCHANGE VISITOR AND CONTACT INFORMATION FAMILY NAME: GIVEN NAME: EMAIL ADDRESS: Page 1 Updated 8/31/2016

PART 3: CULTURAL EXCHANGE PLAN AND AGREEMENT Per Department of State regulations, J-1 Exchange Visitors are required to participate in cultural exchange activities while on program in the United States. KUMC further requires that J-1 participants attend at least one cultural exchange event or activity per month. Please note, J-1 exchange visitors should be expected to provide proof or more information about their plan s progress at OIP s follow-up appointments and at the time of the J-1 extension. Below please provide information on the types of cultural exchange activities the J-1 will engage in for the first year or duration of program. MONTH 1 [ ]: MONTH 5 [ ]: MONTH 9 [ ]: MONTH 2 [ ]: MONTH 6 [ ]: MONTH 10 [ ]: MONTH 3 [ ]: MONTH 7 [ ]: MONTH 11 [ ]: MONTH 4 [ ]: MONTH 8 [ ]: MONTH 12 [ ]: Please note, the Office of International Programs offers several opportunities throughout the year for J-1 participants to attend cultural exchange events, this includes but is not limited to the following: Culture Hour (every Thursday at noon, Calkins Conference Room) http://www.kumc.edu/international-programs/programs-and-events/culture-hour.html Clinical Culture and Diversity Series http://www.kumc.edu/international-programs/programs-and-events/clinical-culture-and-diversity-series.html International Education Week http://www.kumc.edu/international-programs/programs-and-events/international-education-week.html ISI Events http://www.isikansascity.org/ For more information on OIP events, please also visit our Events Calendar available at this link: http://www.kumc.edu/internationalprograms/events-calendar.html. Cultural exchange activities are not limited to OIP events or the list above, activities such as seminars, lectures, or conferences that occur within the department, KUMC, locally, regionally, or nationally count toward fulfilling this requirement. By signing this form, the sponsoring supervisor agrees to allow and encourage the J-1 exchange visitor to participate in at least one cultural exchange activity or event per month. SPONSORING SUPERVISOR SIGNATURE DATE Page 2 Updated 8/31/2016

PART 4: DEEMED EXPORT QUESTIONNAIRE FOR J-1 EXCHANGE VISITOR PROGRAM Export Control Laws: What is a Deemed Export? Export control laws are designed to prevent the export of unlicensed sensitive equipment, software, and technology to ensure U.S. national security and foreign policy objectives. Export control is regulated by multiple U.S. agencies. These laws can result in severe fines and prosecution. This liability applies to KUMC and you as a private citizen. Export of sensitive equipment, software, or technology can occur when it is: Available to foreign nationals for visual inspection (such as reading technical specifications, plans, blueprints, etc.) Exchanged orally Made available by practice or application under the guidance of persons with knowledge The Deemed Export Questionnaire is aimed at determining whether an export license will be required before releasing controlled technology to a foreign person. Please note: information or research data shared within the scientific community or to the public is generally exempt from export control laws under the Fundamental Research clause. Nonetheless, the completion and review of the deemed export questionnaire is still required. -From KUMC Export Controls https://export-compliance.ku.edu/ 1. Will the incoming international s activities involve projects or collaborations that fall under the fundamental research exclusion? If not, is there export controlled technology and or materials including infectious or hazardous agents involved? YES YES NO NO 2. For research funded solely by the University, does the University intend to withhold the research results for proprietary reasons and not share broadly in the scientific community? 3. Will the exchange visitor have access to information regarding how to install, maintain, repair, refurbish and overhaul a particular piece of equipment? 4. Will the exchange visitor be exposed to equipment that was specifically designed or developed for military or outer space applications? 5. Please provide a list of any scientific equipment, including highly specialized computing equipment that the exchange visitor will use in the course of performing his/her duties. Add additional page(s) if needed. SPONSORING SUPERVISOR SIGNATURE DATE FOR OIP USE ONLY J-1 Exchange Visitor s Full Name: Country of Citizenship: Country of Residence: Name of Last Employer in Home Country: Location of Last Employer: Visual Compliance Processing Date: Page 3 Updated 8/31/2016

PART 5: FOREIGN TRAINED PHYSICIAN In some cases, an exchange visitor who is an alien physician or foreign trained physician participating in a program of observation, consultation, teaching or research may need to have limited patient contact in order to carry out those objectives. If the patient contact is incidental to those objectives, a physician participating in a non-clinical exchange program can engage in incidental patient contact. However, Incidental Patient Contact must be approved by the Office of International Programs Responsible Officer, Sponsoring Supervisor, Sponsoring Department Chair, Vice Chancellor for Academic Affairs, and Executive Dean of School of Medicine. If there is reason to believe that incidental patient contact may occur with a prospective exchange visitor physician, please contact the Office of International Programs directly. IS THE J-1 EXCHANGE VISITOR A FOREIGN TRAINED PHYSICIAN? IF YES, WILL THERE BE INCIDENTAL PATIENT CONTACT? If yes, please skip the No Patient Care or Contact section below and complete the Certificate to Supplement Form DS- 2019 form attached in this packet. Please note, we must receive original signatures on this form. All signatures should be in blue ink. PART 6: NO PATIENT CARE OR CONTACT The U.S. Department of State designated the University of Kansas Medical Center to sponsor foreign nationals for the purpose of engaging in scholarly activity including research, teaching, consultation, and observation. The U.S. Department of State regulations strictly prohibits KUMC from sponsoring individuals who will be participating in patient care or clinical activity. By checking this box, the sponsoring department affirms that the prospective J-1 Exchange Visitor will not be involved in any patient care and patient contact if said individual holds credentials that would otherwise permit such activity. PART 7: INFORMATION ABOUT THE POSITION PROGRAM DATES (MM/DD/YYYY): CURRENT DS-2019 EXPIRATION DATE: EXTENSION REQUEST END DATE: POSITION TITLE: POSITION DESCRIPTION (Please describe briefly in 1-2 sentences the exchange visitor s activity and program objectives): WERE THERE ANY CHANGES TO THE POSITION AND DUTIES FROM THE PREVIOUS DS-2019 ISSUED FOR THE J-1 EXCHANGE VISITOR? YES NO IF YES, PLEASE SPECIFY THE TYPES OF CHANGES AND IF APPLICABLE INCLUDE A COPY OF THE UPDATED POSITION DESCRIPTION: Page 4 Updated 8/31/2016

PART 8: INFORMATION ABOUT THE FUNDING INDICATE THE SOURCE OF FUNDING FOR THE EV S POSITION (For more information on J-1 funding policies, please see the DS-2019 Request Additional Information.): KUMC PAID Funding will be provided by KUMC for HR classified titles and paid through KUMC payroll. This includes grant funded positions processed through KUMC payroll. If the position is KUMC paid, please complete Part 8A only and skip Parts 8.B as well as 8.B.1. NON-KUMC PAID Funding is provided by a non-kumc source such as an international scholarship, international grant, personal funds, etc. These positions cannot have HR classified titles and cannot be placed on KUMC payroll. If the position is Non-KUMC paid, please complete Parts 8.B. as well as 8.B.1 only and skip Part 8.A. PART 8.A: KUMC PAID POSITION COMPLETE THIS PART ONLY FOR KUMC-PAID POSITIONS Please note the following for KUMC paid positions: Funding must meet HR minimums for each position classification, unless otherwise approved by HR. o Please see DS-2019 Request Additional Information for more details. J-1 sponsored positions that are also KUMC paid must be 1.0 FTE or full time. HR classified positions cannot be supplemented with outside sources of funding. Postdoctoral Fellow positions are exempt and have to meet the minimum annual salary requirement of $47, 476. Postdoctoral Fellow positions must be 1.0 FTE or full time. KUMC funded positions may request program duration of more than one year as long as it is within the maximum duration of the J-1 category. EV will still be required to complete an annual review with OIP. TOTAL FUNDING AMOUNT (USD): $ DURATION OF FUNDING (MONTHS): PART 8.B: NON-KUMC PAID POSITION COMPLETE THIS PART FOR NON-KUMC PAID POSITIONS ONLY Please note the following for non-kumc paid positions: Minimum funding for non-kumc paid positions: o J-1: $27,720 for 12 months, or $2310 per month o J-2: $5,000 for 12 months (for each J-2 dependent), or $416.67 per month Non-KUMC paid J-1s cannot be classified under HR titles. These individuals will be assigned separate titles such as Visiting Researcher, Research Scholar, Visiting Professor, or Visiting Lecturer. Sponsoring departments have the option to supplement the prospective EV s funding. However, this amount can only be paid in a form of an award and the EV will not be placed on payroll. Please note, Accounts Payable must approve and create a Glacier record prior to issuance of an award. o An award is an amount of money a KUMC department pledges toward the support of a non-kumc paid Exchange Visitor to help with expenses or to offset expenses incurred by the EV while being hosted by the department. When an EV receives an international scholarship or grant whether from home government or their employer, personal funds can be used to supplement it in order to meet KUMC s minimum funding threshold. In cases where the employer is continuing the EV s salary as a means of proof of funding, personal funds cannot be accepted in these situations. Any funding issued by the EV s employer or university will require signing an agreement between this institution and KUMC. The agreement will outline the terms of the funding and its purpose. EVs who receive a scholarship or grant from outside sources and who are providing personal funds will be limited to a one year experience. Exceptions must be reviewed and approved by OIP, Vice Chancellor for Academic Affairs and Vice Chancellor for Research. Page 5 Updated 8/31/2016

Proof of funding not older than six months must be provided for all non-kumc paid sources of funding. o Proof of funding documents must be copies of originals or certified copies, printed on official letterhead or equivalent. If the document is not in English, a certified translation must be attached to the original copy. o OIP will request these proof of funding documents directly from the J-1 exchange visitor. PART 8.B: NON-KUMC PAID POSITION CONTINUED COMPLETE THIS PART FOR NON-KUMC PAID POSITIONS ONLY PLEASE PROVIDE AN EXPLANATION AND REASONS FOR SEEKING AN EXTENSION OF A NON-KUMC PAID POSITION BEYOND THE ONE-YEAR ON A J-1 STATUS. FOR OFFICE USE ONLY APPROVED NOT APPROVED Page 6 Updated 8/31/2016

PART 8.B: NON-KUMC PAID POSITION CONTINUED COMPLETE THIS PART FOR NON-KUMC PAID POSITIONS ONLY TOTAL FUNDING AMOUNT (USD): $ DURATION OF FUNDING (MONTHS): WILL THE DEPARTMENT PROVIDE AN AWARD TO SUPPLEMENT A PORTION OF EV S FUNDING FOR THE J-1 EXPERIENCE? If yes, please include amount, source of funding, and type of grant details below in the Source of Funding Information section. WILL EV S EMPLOYER OR UNIVERSITY PROVIDE FUNDING FOR THE DURATION OF THE J-1 PROGRAM? If yes, please note OIP will need to obtain a signed general agreement with the J-1 s employer or university if it is not already on file with OIP. OIP cannot issue DS-2019 until agreement is on file. SOURCE OF FUNDING INFORMATION: AMOUNT (IN USD) TYPE (i.e. grant, scholarship, etc.) SOURCE (i.e. institution issuing funds) FUNDING COUNTRY OF ORIGIN FOR ACCOUNTS PAYABLE USE ONLY Award Amount: $ Tax Liability Amount: $ Approved Name of Reviewer: Not Approved Date: Page 7 Updated 8/31/2016

PART 8.B.1: RESEARCH PLAN COMPLETE THIS PART FOR NON-KUMC PAID POSITIONS ONLY The completion of the Research Plan is required for all NON-KUMC PAID positions. 1. What is the research focus of the lab? 2. What research projects and/or duties will the J-1 Exchange Visitor undertake? 3. What are the main goals and objectives for the J-1 Exchange Visitor for the duration of their program? 4. What is the anticipated duration of the research experience for the J-1 Exchange Visitor? 5. Are there any publications that could result from the research experience? 6. Please provide any additional information related to the J-1 Exchange Visitor s research experience and objectives. FOR OFFICE USE ONLY APPROVED NOT APPROVED Richard J. Barohn, M.D. Vice Chancellor for Research Chairman, University Distinguished Professor, Gertrude & Dewey Ziegler Professor DATE Page 8 Updated 8/31/2016

DEPARTMENT STATEMENT OF RESPONSIBILITY As a sponsoring department, we agree and attest to the following terms when sponsoring a J-1 Exchange Visitor: Provide accurate program, funding, and other related information throughout the duration of the J-1 s program at KUMC. This includes: o Cancellation of EV s program o Intent to transfer to another KUMC department or sponsor o Termination or early completion of program o Significant changes in position/project o Changes in funding sources and amounts o Plans to change status o Attend classes Encourage the J-1 to participate in cultural exchange activities to ensure compliance with Department of State s requirements. This includes: o Attending one cultural exchange event every month. "Ensure that the activity in which the exchange visitor is engaged is consistent with the category and activity listed on the exchange visitor's Form DS-2019." [62.10(e)(1)]. This means that the EV should maintain his or her original program objectives as indicated on the initial DS-2019 request and form. J-1s whether classified as KUMC paid or Non-KUMC paid have the same access to benefits and rights as any other employee. This includes but is not limited to: o Attendance and overtime policies Exchange visitors should be aware of typical hours of operation within their department and/or lab. Full-time employment is generally considered working 60 to 100 hours per pay period (every two weeks). Hours worked should not exceed more than 50 hours per week. Non-KUMC paid exchange visitors should track hours worked in a timesheet that is signed off by the sponsoring supervisor per pay period. Office of International Programs should be notified of exchange visitor s absenteeism. If there has been no contact with the exchange visitor for at least 24 hours, the Office of International Programs should be notified immediately. If there has been contact with the exchange visitor, but he or she has been absent for five days with no valid reason, the Office of International Programs should be contacted. o Vacation and other type of leave policies Exchange visitors should be aware of vacation and other types of leave available such as vacation, sick leave, family or medical leave, and funeral or death leave. Exchange visitors accrue leave hours in accordance with HR policies. o Safe and clean working conditions o Receive the necessary training to perform job functions o Receive KUMC badge o Have KUMC network access and email o Be aware of harassment policies o Be aware of sexual harassment policies o Inclusion in meetings, seminars, and other department activities o Retaliation and threat of retaliation policies will not be tolerated J-1 exchange visitors can be accompanied by dependents. Dependents are defined as the spouse and/or child/children of the exchange visitor. J-1s must have sufficient funds to support each dependent. Update the deemed export questionnaire if any changes occur to the J-1 exchange visitor s program that may affect export compliance. Request to extend the program dates for a J-1 EV as long as the EV has been maintaining status, complies with KUMC s funding requirements, and is still within the maximum duration of the J-1 category. Department Administrator s Name: Department Administrator s Signature: Date: Sponsoring Supervisor Name: Sponsoring Supervisor Signature: Date: Department Chair Name: Department Chair Signature: Date: Page 9 Updated 8/31/2016

PREPARER S ACKNOWLEDGMENT By signing this document, I affirm that I had permission to prepare this form and I attest that all information included in this request document is true and correct. SIGNATURE: NAME: DATE: DS-2019 EXTENSION REQUEST PROCESS OVERVIEW 1. SPONSORING DEPARTMENT SUBMITS THE FOLLOWING TO OIP: a. Completed DS-2019 extension request form 2. OIP CONTACTS EV AND SCHEDULES A FOLLOW UP APPOINTMENT 3. EV SUBMITS THE FOLLOWING TO OIP: a. Completed EV extension questionnaire update form b. Proof of health insurance coverage that meets U.S. Department of State requirements 4. OIP PROCESSES DS-2019 EXTENSION REQUEST ONCE CONFIRMING ALL REQUEST DOCUMENTS WERE RECEIVED AND EV ATTENDED FOLLOW UP APPOINTMENT a. OIP has a 10-day turn around policy for issuing DS-2019 documents. 5. OIP ISSUES DS-2019 AND NOTIFIES THE SPONSORING DEPARTMENT, HUMAN RESOURCES, AND THE EV. 6. EV OR SPONSORING DEPARTMENT CAN PICK UP THE ORIGINAL DOCUMENT AT WESCOE 5010 7. EV WILL NEED TO PROVIDE A COPY OF THE NEW DS-2019 FORM TO THE SPONSORING DEPARTMENT AND HUMAN RESOURCES. Page 10 Updated 8/31/2016

CERTIFICATION TO SUPPLEMENT FORM DS-2019 ALIEN PHYSICIAN PARTICIPATION IN A NON-CLINICAL EXCHANGE VISITOR PROGRAM WITH INCIDENTAL PATIENT CONTACT AT THE UNIVERSITY OF KANSAS MEDICAL CENTER (P-2-03624) Program Start Date: Program End Date: J-1 Exchange Visitor: This certification statement affirms that an Alien Physician or a physician trained outside of the United States will participate in a nonclinical Exchange Visitor Program at the University of Kansas Medical Center that will involve observation, consultation, teaching or research with limited or incidental patient contact in order to carry out those objectives. The Alien Physician will not engage in patient care. Incidental contact with patients will not compromise the care of the patients and will occur in the presence of a senior physician holding a current medical license from the State of Kansas. In accordance with 22 C.F.R. 62.27(c)(1)(ii), we certify the following: (A) The program in which will participate is predominantly involved with observation, consultation, teaching, or research. (B) Any incidental patient contact involving the alien 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 Kansas. (C) The alien physician will not be given final responsibility for the diagnosis and treatment of patients. (D) Any activities of the alien physician will conform fully with State of Kansas licensing requirements and regulations for medical and health care professionals in the State of Kansas in which the alien physician is pursuing the program. (E) Any experience gained in this program will not be creditable toward any clinical requirements for medical specialty board certification. Additionally, we certify that described duties and parameters: s patient contact will consist of the following and will not exceed these Irina Aris Responsible Officer (RO), Signature Date Sponsoring Supervisor Name Sponsoring Supervisor Signature Date Department Chair Name Department Chair Signature Date Robert Simari, M.D. Executive Dean, School of Medicine, Signature Date Robert M. Klein, Ph.D. Vice Chancellor for Academic Affairs Signature Date Page 11 Updated 8/31/2016