J-1 EXCHANGE VISITOR PROGRAM AT KUMC EXCHANGE VISITOR EXTENSION QUESTIONNAIRE UPDATE (DS-2019 REQUEST: NON-KUMC PAID)

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 J-1 EXCHANGE VISITOR PROGRAM AT KUMC EXCHANGE VISITOR EXTENSION QUESTIONNAIRE UPDATE (DS-2019 REQUEST: NON-KUMC PAID) 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 EXCHANGE VISITOR EXTENSION QUESTIONNAIRE UPDATE FORM SCHEDULE AND ATTEND FOLLOW UP APPOINTMENT WITH OIP PROOF OF HEALTH INSURANCE COVERAGE THAT MEETS U.S. DEPARTMENT OF STATE REQUIREMENTS SUBMIT A SCANNED COPY OF THE REQUEST FORM WITH SUPPORTING DOCUMENTS BY EMAIL TO BOTH ALEXANDRIA HARKINS (aharkins2@kumc.edu) AND IRINA ARIS (iaris@kumc.edu). PART 1: BIOGRAPHICAL INFORMATION EMAIL ADDRESS: TELEPHONE NUMBER: SOCIAL SECURITY NUMBER (if applicable): CURRENT ADDRESS (where you live, cannot be place of employment): ADDRESS (street name and number): CITY: PROVINCE/STATE: COUNTRY: ZIP/POSTAL CODE: PERMANENT ADDRESS (complete if different from above address): ADDRESS (street name and number): CITY: PROVINCE/STATE: COUNTRY: ZIP/POSTAL CODE: 1 P age

PART 2: 212 (e) CERTIFICATION FORM Please complete and sign this form. Mail Stop 3033, 3901 Rainbow Blvd., Kansas City, KS 66160 I am a J-1 exchange visitor. A department at the University of Kansas Medical Center has requested to extend my J-1 Exchange Visitor status. PLEASE SELECT THE APPROPRIATE ITEM: As documented on my DS-2019 and/or J-1 Visa Stamp; I am not subject to Section 212(e), the two year home country physical presence requirement. I am subject to Section 212(e), the two year home country physical presence requirement. If subject to Section 212(e), I understand that I am ineligible for an extension of my J-1 status once I have made application for a waiver of Section 212(e) and the U.S. Department of State has issued a letter of no objection ; I may fulfill the terms of my current program only. Furthermore, the Responsible Officer (RO) or Alternate Responsible Officer (ARO) in accordance with the regulations is unable to issue an extension of the DS-2019 in this situation. If the U.S. Department of State or the U. S. Citizenship and Immigration Service (USCIS) denies my waiver application, I remain in J- 1 status (provided no violations have occurred), and transfers and extensions may be processed in the usual manner. I understand that providing false or misleading information is grounds for denial of a waiver application, extension, or continuation in program status. PLEASE SELECT THE APPROPRIATE ITEM: I have not made an application for waiver of Section 212(e). submitted an application for waiver of Section 212(e), but have not received a letter or no objection from the DOS. received a letter of no objection from the U.S. Department of State and am waiting for a response from the USCIS (attach a copy of the DOS letter and/or USCIS receipt notice). been granted a waiver to Section 212(e) by the USCIS (attach a copy of the Notice of Action). applied for and been denied a waiver by the DOS or the USCIS. J-1 EXCHANGE VISITOR S NAME (AS LISTED ON PASSPORT): DATE OF BIRTH: J-1 EXCHANGE VISITOR S SIGNATURE: DATE: 2 P age

PART 3: PROOF OF HEALTH INSURANCE COVERAGE J-1 PROGRAM: DEPARTMENT OF STATE HEALTH INSURANCE MINIMUM COVERAGE REQUIREMENTS GENERAL: ACCIDENT AND ILLNESS Minimum of $100,000 per accident or illness for medical benefits Maximum co-insurance of 25% Maximum deductible of $500 per accident or illness Waiting period for pre-existing conditions consistent with current industry standard Coverage for all activities that are part of the exchange program MEDICAL EVACUATION Minimum of $50,000 allowed for expenses related to the medical transport of the exchange visitor to his/her home country REPATRIATION Minimum of $25,000 allowed for expenses related to the transport of bodily remains (in the event of death) to the exchange visitor s home country PLEASE SELECT THE APPROPRIATE ITEM ABOUT HEALTH INSURANCE COVERAGE: I have general health insurance coverage through KUMC and I am enrolled in Plan A. I have medical evacuation and repatriation coverage through another provider that meets the minimum requirements listed above. health insurance coverage through another provider and it meets the minimum requirements listed above for both general coverage and medical evacuation as well as repatriation coverage. PLEASE PROVIDE THE FOLLOWING SUPPORTING DOCUMENTS: If you are enrolled in KUMC Plan A and you have medical evacuation and repatriation coverage through another provider, please attach these items: Proof of KUMC health insurance coverage Attach most recent card Attach printout of the benefits screen from HR/Payroll System Proof of Medical Evacuation and Repatriation coverage Please be sure that proof includes coverage start and expiration dates as well as minimum allowed expenses If you are enrolled in health insurance coverage through another provider, please attach these items: Proof of health insurance coverage Attach most recent card Attach brochure/confirmation that outlines minimum amounts for general coverage (accident/illness medical benefits, maximum co-insurance, maximum deductible) Proof of Medical Evacuation and Repatriation coverage Please be sure that proof includes coverage start and expiration dates as well as minimum allowed expenses For J-1 Exchange Visitors who are accompanied by J-2 dependents, please include proof of health insurance coverage that meets the minimum requirements listed above for each dependent. Please note, J-2 dependents should have valid health insurance coverage while the J-1 s record is in active status regardless if the J-2 is outside of the United States. ACKNOWLEDGEMENT As a J-1 Exchange Visitor, I understand and agree to comply with the J-1 Program s health insurance requirements. J-1 EXCHANGE VISITOR S SIGNATURE: DATE: 3 P age

PART 4: INFORMATION ABOUT POSITION AND FUNDING POSITION TITLE: TOTAL FUNDING AMOUNT (USD): List all sources and amounts of funding in the Source of Funding Information below. DURATION OF FUNDING (MONTHS): $ WILL YOUR HOME COUNTRY EMPLOYER OR UNIVERSITY PROVIDE FUNDING FOR THE DURATION OF THE J-1 PROGRAM? If yes, a signed general agreement between KUMC and your employer or university should be on file with OIP. KUMC s general agreement is attached in this packet. Please note OIP cannot issue the DS-2019 until a signed 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 ATTACH PROOF OF FUNDING FOR ALL SOURCES PROOF OF FUNDING REQUIREMENTS: OUTSIDE KUMC FUNDING TITLE Visiting Researcher, Research Scholar Visiting Professor, Visiting Lecturer OUTSIDE KUMC MINIMUM FUNDING AMOUNT (ANNUAL) $27,720 (for J-1) $5,000 (for each J-2 dependent) $27,720 $5,000 (for each J-2 dependent) MAXIMUM DURATION 1 year (6 months for short-term scholars) 1 year (6 months for short-term scholars) General requirements: o Proof of funding documents must be copies of originals or certified copies, printed on official letterhead or equivalent. o If the document is not in English, a certified translation must be included. o Proof of funding cannot be older than 6 months from submission of this request. Requirements based on type of funding: o International scholarship, home government grant, or other organization award: Provide copies of official notification of scholarship, grant, or related funding issuance Proof of funding should indicate amount and duration of support o Home country employer or university support: Provide copies of official notification of employer or university support Proof of funding should indicate amount and duration of support Signed General Agreement for Cultural, Education, and Research Cooperation (attached in this packet) o Personal funds: A recent bank statement or letter from bank (in English or a certified translation) that shows available funds for the proposed exchange visit. Please note personal funds can only supplement the total funding amount, but cannot be the sole source of funding. 4 P age

PART 5: APPLICATION FOR J-2 DEPENDENTS *COMPLETE ONLY IF APPLICABLE Complete this part if you will have dependents accompanying you for the duration of your program at KUMC. Repeat this page as necessary for additional family members. WHAT IS A J-2? A J-2 is a visa type for dependents of a J-1 Exchange Visitor. WHO IS ELIGIBLE TO BE A J-2 DEPENDENT? J-2 dependents can only be the spouse and/or child/children of the J-1 exchange visitor. Children over the age of 21 are not eligible for J-2 status. MINIMUM FUNDING REQUIREMENTS: In order for DS-2019 documents to be issued for your J-2 dependents, the J-1 Exchange Visitor must show that he or she will have sufficient funds to support all dependents. Please reference the following minimum funding requirements: 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 BENEFITS OF BEING A J-2 DEPENDENT: Accompany the J-1 Exchange Visitor to the United States while the J-1 pursues his or her program objectives. J-2 dependents can study and obtain work authorization (EAD card) while in the United States. ADDITIONAL INFORMATION: J-2 dependents visa status is valid as long as the J-1 Exchange Visitor is maintaining status. J-2 dependents must carry health insurance coverage at all times while the J-1 Exchange Visitor s program is active even when the J-2 dependent is outside the United States. DO YOU HAVE DEPENDENT FAMILY MEMBERS (SPOUSE/CHILDREN) WHO YES WILL NEED J-2 STATUS? If no, please skip the rest of part 6. If yes, please complete the rest of part 6 and NO attach passport identification pages for each dependent. PLEASE INDICATE THE DURATION OF STAY FOR EACH J-2 DEPENDENT. SPOUSE: CHILD 1: CHILD 2: CHILD 3: Please note if your dependents will be visiting you for brief stays while you are on the J-1, it is recommended that your dependents obtain a visitor s visa or come on the Visa Waiver Program if eligible instead of the J-2. DEPENDENT 1: RELATIONSHIP TO EXCHANGE VISITOR (J-1): GENDER: SPOUSE CHILD MALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: FEMALE COUNTRY OF CITIZENSHIP: IS THE DEPENDENT CURRENTLY IN THE UNITED STATES? HAS THE DEPENDENT EVER HELD J-1 OR J-2 STATUS? If yes, indicates dates each status held: 5 P age

PART 5: APPLICATION FOR J-2 DEPENDENTS CONTINUED *COMPLETE ONLY IF APPLICABLE DEPENDENT 2: RELATIONSHIP TO EXCHANGE VISITOR (J-1): GENDER: SPOUSE CHILD MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: COUNTRY OF CITIZENSHIP: IS THE DEPENDENT CURRENTLY IN THE UNITED STATES? HAS THE DEPENDENT EVER HELD J-1 OR J-2 STATUS? If yes, indicates dates each status held: DEPENDENT 3: RELATIONSHIP TO EXCHANGE VISITOR (J-1): GENDER: SPOUSE CHILD MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: COUNTRY OF CITIZENSHIP: IS THE DEPENDENT CURRENTLY IN THE UNITED STATES? HAS THE DEPENDENT EVER HELD J-1 OR J-2 STATUS? If yes, indicates dates each status held: DEPENDENT 4: RELATIONSHIP TO EXCHANGE VISITOR (J-1): GENDER: SPOUSE CHILD MALE FEMALE DATE OF BIRTH (mm/dd/yyyy): CITY OF BIRTH: COUNTRY OF BIRTH: COUNTRY OF CITIZENSHIP: IS THE DEPENDENT CURRENTLY IN THE UNITED STATES? HAS THE DEPENDENT EVER HELD J-1 OR J-2 STATUS? If yes, indicates dates each status held: ACKNOWLEDGMENT By signing this document, I attest that all information included in this request document is true and correct. J-1 EXCHANGE VISITOR S SIGNATURE: DATE: 6 P age

J-1 EXCHANGE VISITOR STATEMENT OF RESPONSIBILITY As an Exchange Visitor, I agree and attest to the following terms when on the J-1 program at the University of Kansas Medical Center: Notify OIP of arrival in Kansas City and attend check-in/validation appointment as well as the J-1 Orientation program. o The check-in/validation should occur no later than 3 days after arriving in Kansas City. o If check-in does not occur within 30 days before or after the program start date indicated on the DS-2019, the exchange visitor s record will become invalid and out of status regardless of the J-1 visa stamp validity. Provide the following documents and information at check-in/validation appointment: o Passport, DS-2019, U.S. Visa Stamp, I-94, Physical Address in the United States, Contact Information, Emergency Contact Information, and Proof of Health Insurance that meets U.S. Department of State requirements Ensure the compliance with the U.S. Department of State health insurance requirements as specified at 22 C.F.R. 62.14. o medical benefits of at least $100,000 per accident or illness; o repatriation of remains in the amount of $25,000; o expenses associated with medical evacuation of the exchange visitor to his or her home country in the amount of $50,000; o a deductible not to exceed $500 per accident or illness; and o maximum co-insurance of 25% 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 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. 7 P age

Mail Stop 3033, 3901 Rainbow Blvd., Kansas City, KS 66160 J-1 EXCHANGE VISITOR STATEMENT OF RESPONSIBILITY CONTINUED 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 Provide sufficient funds to support each dependent if applicable. Will not engage in any patient care or patient contact. Understand that incidental patient contact can occur only if a Certificate to Supplement DS-2019, Incidental Patient Contact form is appended to the DS-2019 document. J-1 EXCHANGE VISITOR S NAME: J-1 EXCHANGE VISITOR S SIGNATURE: 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. 8 P age