J-1 Exchange Visitor Program Sponsorship Form

The Hosting Unit acknowledges and understands that it must notify the OIS prior to changing any of the terms and conditions of the J-1 Exchange Visitor’s Program (e.g. salary/stipend/funding source, work-site location, change of academic or research responsibilities, etc.) during the pendency of the Program. Failure to adhere to this essential Program requirement could result in termination of the Exchange Visitor Program.

This form is a fillable form (Electronic Version)

SECTION I EXCHANGE VISITOR INFORMATION

1 / Name: Last or Family First Middle
!!PLEASE PROVIDE THE OIS WITH A COPY OF THE PASSPORT INFORMATION PAGE!!
2 / Birthdate: (mm/dd/yyyy) / 3. Birth City: Birth Province: Birth Country:
4 / Degree(s) held at time of request: BA BS MS MD or foreign equivalent Ed.D Ph.D Other: Please select one description from the two options below:
a). Visitor will be engaged solely in observation, consultation, teaching, or research and NO ELEMENT OF PATIENT CONTACT/CARE WILL BE INVOLVED in the Exchange Visitor Program, or
b). Visitor is an MD and WOULD LIKE to have Incidental Patient Contact. (Sample letter available)
5 / Country of Permanent Legal Residence:
6 / Country of Citizenship:
7 / Current Position/Occupation in Home Country:
8 / Name of Current Employer/Organization in Home Country:
9 / Current address abroad: (PO Box not acceptable): Street Name & Number: Apt / House #:
Province / City: Country: Postal Code:
E-mail Address: Tel. # Fax #

SECTION II PROGRAM INFORMATION

10 / UTHSCSA Host Unit:
Please Note: Host Unit refers to 1) which campus unit will have overall responsibility for the Visitor during the Program, and 2) if direct payment is involved, what unit will bear the fiscal costs of the visit?
11 / Name and title of the person to whom the Visitor will report directly: Email: @uthscsa.edu
12 / Projected Program start date: Projected Program end date:
Total estimated time necessary to complete the Program:
13 / Will funding be paid by UTHSCSA? Yes No If yes, Partial Full
Compensation per month/year $ Please indicate if this amount is monthly or yearly.
14 / Will funding be provided by a source other than UTHSCSA? Yes No If yes, Partial Full
Extramural funding source amount, per month or per year $Please indicate if this amount is monthly or yearly.
Please Note: If any amount of funding will beprovided by an extramural source, the OIS must have evidence of the funding source, amount, and duration. This is typically provided via a funding or award letter (on letterhead) that is provided to the Visitor directly by the funding source.
15 / UTHSCSA NOW REQUIRES MINIMUM LEVELS OF FUNDING FOR CERTAIN J-1 ACTIVITIES: The minimum amount of funding should total at least$20,597 per year for a J-1 “Visiting Student”. For Postdoctoral Research Fellows, “Visiting Professors”, and “Visiting Scientists” the minimum amount of funding per year should be at least $26,000. J-1 dependent family members will require additional funding levels of at least$4,675 per year, per family member.
16 / Please answer the following questions if the Visitor will be compensated by the University:
  1. Will the Visitor be an employee of the University and, therefore, eligible for UT Select health coverage?
Yes No
*There is a University-mandated 90-day waiting period for medical coverage for newly hired employees*
B. Is this a faculty position? Yes No If yes, please contact the OIS immediately!
17 / Proposed Title (TO BE USED IN THE OFFICIAL OFFER LETTER): Visitor’s Specialization or Field of Endeavor (For example, Chemistry):
Note: Visitors paid by the University will require special advance approval by the Office of Human Resources. Hosting units should not use classified personnel titles when hosting Exchange Visitors. Hosting Units should not appoint a foreign national as a “POI” for any reason.
18 / Non-technical description of the activity the Visitor will be engaged in under this Program. (no more than 40 words)
19 / Primary site of J-1 Program activity:
Please be specific as to building name, campus location. Will the Visitor be located in more than one site or location? If yes, please explain:

SECTION III COMPLETE ONLY IF VISITOR WILL HAVE J-2 DEPENDENTS

20 / List the Names, Relationships, Citizenships, Birthdates, and Birthplaces of ALL Dependent Family Members (Spouse and Unmarried Children Under the Age of 21 Only) who will accompany the Visitor.
Please Note:The minimum amount of funding is $4,675 per family dependent, per year.
!!PLEASE PROVIDE A COPY OF THE PASSPORT INFORMATION PAGE FOR EACH DEPENDENT!!
Family Name / Given Name / Middle Name / Relationship to applicant / Country of Citizenship / Country of Legal Permanent Residence / City and Country of Birth / Birth Date (mm/dd/yyyy)

SECTION IV COMPLETE ONLY IF VISITOR IS PRESENTLY IN U.S.A.

21 / Present Visa Status: Program Dates: From to
22 / U.S. Employer’s name: Address: Tel. # Fax #
23 / UTHSCSA Badge Number and Host Unit ( if applicable):

SECTION V HOST UNIT CONTACT INFORMATION

24 / Host Unit contact name:
25 / Host Unit contact person’s e-mail address:
26 / Host Unit contact person’s telephone number:
27 / Host Unit contact person’s fax number:
28 / Host Unit contact person’s User Name for E-ship Global:
Departmental Project ID:

PLEASE NOTE: The OIS will send the initial Form DS-2019 to the prospective Exchange Visitor via express mail service. However, if a Form is re-issued for any reason, the Hosting Unit will be charged for shipment of the new Form DS-2019.

CHECK-LIST for UTHSCSA HOST UNITS

1. J-1 Exchange Visitor Program Sponsorship Form

2. Copy of Exchange Visitor’s Passport Information (Name) Page

3. Copy of the Visitor’s resume/CV- must have English translation if not in English language

4. Copy of diploma of highest degree the applicant received – must have English translation if not in English language

5. Copy of Offer Letter from UTHSCSA department signed by Chair and/or Administrator stating the Program start and ending date, funding/compensation amount and duration (if receiving funding from UTHSCSA), and a description and objective of the Program, the role of the Visitor, etc. **If no stipend is offered by UTHSCSA, the applicant must show evidence of extramural support, which can be in the form of an Official Award Letter from another funding source (Ex: scholarship, governmental support, etc…). Please Note: Exchange Visitors may NOTuse personal funding to support the exchange program objective.**

6. Proof of Health Insurance Coverage:

  • If the Visitor is paid/compensated by UTHSCSA, proof of coverage is needed for the first three months of employment.
  • If the Visitor is not paid by UTHSCSA, insurance coverage is required for the duration of stay.
  • In all cases, Visitors will be required to attest that they will obtain/maintain health insurance coverage for themselves and their dependent family members.

7. J Program Conditions Statement

8. Incidental Patient Contact Letter OR Statement of No Patient Contact

*Transfer Requests for Exchange Visitors who are IN THE U.S. in J-1 visa status must also provide:

Copies of ALL previously issued Forms DS-2019/IAP-66, Forms I-94 (both sides), all J-1 visas issued to

the Exchange Visitor.

Transfer-In Clearance Form. (!!!THIS FORM IS REQUIRED!!!)

OFFICE OF INTERNATIONAL SERVICES | Mail Code 7971 | 7703 Floyd Curl Drive | San Antonio, Texas 78229-3900

Tel. 210.567.6241 | Fax 210.567.6240 |