Questions for DS-2019

Please provide the following information along with the required documents listed below and email your responses to

General Information

Last name (as appears on passport):

First name (as appears on passport):

Male or female

Date of birth

Married: Yes or No

City of birth

Country of birth

Country of citizenship

Country of Permanent Residence

Email Address:

Primary Phone Number:

Permanent Address Outside of US

Street Address:

Room #:

City:

State/Province:

Postal Code:

Country:

Mailing Address (may be within or outside of US):

Street Address:

Room #:

City:

State/Province:

Postal Code:

Country:

Program Information

Appointment Date (mm/dd/yyyy)

From:

To:

Subject of Activity (research at UCLA, no more than 15 words):

Occupation and Education

What is your current or last activity in your home county (country of citizenship/permanent residence)?: Student, Researcher, Professor, or Other (please list)

If currently enrolled as a student please specify the level, name of institution and expected date of degree:

If employed, specify title and name of employer:

Highest Academic Degree earned (BS, MS, PhD, etc.):

Date Awarded (MM, YYYY):

Previous J Visa History:

During the last 2 years have you been issued any J-1 and/or J-2 Status in the US: Yes or No

Are you currently in the US: Yes or No

If Yes, under which visa type?

Financial Support Information

List for the entire period covered by this form, specify in US Dollars.

Funding Source / Monthly Amount: / Total Amount:
UCLA Department budget, grant, etc.
Exchange Visitor’s Government (attach financial document)
Name of Agency:
Other organizations/institutions in the US or abroad (attach financial document)
Name(s):
Personal funds (attach copy of bank statement in English)

Is at least 51% of financial support must be from non-personal or family sources? Yes/No

Dependent Information

Copy of Dependent passport is required

For each dependent list the following:

Last, First Name (as appears on passport):

Relationship: Spouse, Daughter, Son

Date of Birth (MM,DD,YYYY):

City of Birth:

Country of Birth:

Country of Citizenship:

Country of Permanent Residence:

Email:

Phone Number:

Medical Insurance

Indicate if you will enroll or waive VSISP medical insurance:

J-1 visitors at UCLA (other than those visitors who fall under the designated groups below) are required to enroll OR opt out of the Visiting Scholar Injury and Sickness Insurance Plan (VSISP) through Garnett-Powers & Associates. In order to opt out of the VSISP plan, J-1 visitors are required to show proof of health insurance with the following minimum coverage:

  • All $100,000 per accident or illness.
  • An annual deductible not exceeding $250.
  • $50,000 minimum coverage for expenses associated with the medical evacuation to the visitor’s home country. (international only)
  • $25,000 minimum coverage for expenses associated with repatriation of remains to exchange visitor's home country. (international only)
  • Pre-existing conditions must be covered after a 12-month waiting period.
  • Coverage may include a provision for maximum 25% coinsurance or co-payment paid by the visitor. Coinsurance must allow for customary & reasonable charges in US dollars, not equivalent cost for services in home country.
  • Coverage cannot exclude benefits for perils inherent to the activities of the program in which the visitor participates.
  • Policy must be underwritten by an insurance corporation meeting the US Department of State rating requirements or backed by the full faith and credit of the visitor's home country government, designated sponsor, or exchange visitor's employee group plan.

Information regarding eligibility, requirements, enrollment and the waiver approval process can be found on the Garnett-Powers site at . VSISP enrollment confirmation will be sent to the J-1 visitor by email. Visitor must print and bring for check-in. Those approved for the waiver, must bring their waiver confirmation and proof of medical insurance used to waive.

Fees

Have you read and understood the VGR fees posted at Yes/No

Do you understand that some of these fees are non-refundable? Yes/No

jPATH

As an international J-1 scholar or non-degree student you are required to complete a J-1 orientation per U.S. Department of State regulations. UCLA jPATH Orientation is composed of several components that must be completed by the end of week 2 of your UCLA program. You will receive information about jPATH when issued a DS-2019 form, but you should be aware that failure to complete jPATH may also lead to the cancellation of your J-1 visa status since orientation is a U.S. Department of State requirement. More information about the program can be found here –

Please indicate that you understand this requirement by typing “I understand” below:

Required Documents

  • Resume/CV
  • Copy of picture page of passport
  • Copy of picture page of passports of dependents (if applicable)
  • Proof of financial support (see DS-2019 instructions for requirements -
  • Health insurance information (See Exchange Visitor Regulation Guidelines -
  • English Language Proficiency form (Form is available here -
  • Proof of registration (required for Visiting Graduate Students only – See VGR website for more details -
  • If issued a J-1 in the past 2 years, you must also submit copies of your previous DS-2019s