REQUEST FOR EXTENSION OF

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REQUEST FOR EXTENSION OF Powered By Docstoc
					Please complete and return the following materials to SISS                                    Time Limits for Each J Category
30 days before the current DS-2019 expires:
   1. This Request for Extension                                                              Short-term Scholar                     6 months
   2. Documentation of funding (if not salaried by UCD)                                       Specialist                             12 months
   3. DaFIS # (See Sec. A.10.)                                                                Research Scholar/Professor             5 years
   4. Memo from inviting faculty member (See Sec. A.5)
   5. Attachment for J-1 Physician (if applicable; see instructions)

                                                        REQUEST FOR EXTENSION OF
                                                       EXCHANGE VISITOR (J-1) STATUS
                  Return this request to SISS at least 30 days before the expiration date on the current DS-2019 form.
Part A: To be completed by the University of California, Davis or UCDMC Department (Please type)

1.     Name:
                                         family/last                                       given/first                             middle
2.     Date J-1 status first obtained:
3.     Expiration date of current Form DS-2019 (shown in section #3 of the DS-2019):
4.     UC Davis position title:                   title code:                             NO UCD position title code:
5.     Attach a memo written on official letterhead from host faculty member with non-technical description of proposed activity, work
       location, salary, benefits, and dates.
6.     If scholar has M.D. degree, complete Attachment for J-1 Physician
7.     Period of extension for which funding is guaranteed:            from:                             to:
                                                                                 mm/dd/yyyy                                mm/dd/yyyy
8.     FINANCIAL SUPPORT: Indicate the source and amount of total guaranteed financial support for the entire period in #7. Beginning
       July 1, 2010, the required minimum funding support for scholars and their families is $1,800 per month for the scholar, $500 per
       month for a spouse and $230 per month for each child (not including health insurance or childcare expenses).

       NOTE:         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 a) UCD as payroll.
       Please include funding information for the ENTIRE extension period listed in #7 above:

        a.    UCD (specify payroll, honorarium, per diem):                                                     Amount:$
        b.    U.S. Government Agency:                                                                          Amount:$
        c.    Exchange Visitor’s Government: ……………………………………………………………                                           Amount:$
        d.    Other (specify):                                                                                 Amount:$
        e.    Personal Funds: ………………………………………………………………………………                                                   Amount:$
             Total funding for the initial visit period: ………………………………………………….                                  Amount:$

             Written verification (in English and U.S. dollars) is required for financial support not provided by UCD.
 9.     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)

 10. 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 $354 ($415 if request
 received after 11/30/2011) 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



UCD School of Medicine Appointments:         Dean’s Office Signature                                                                        Date
DS-2019 extension/rev. 11/15/11



Part B. All questions to be completed by scholar and returned to inviting UCD department.
1.     Local
       Address:
                                Number/Street        City          State           Zip          Home         Campus               e-mail
                                                                                                Phone         Phone
2. Do you plan to travel outside the U.S. before the expiration date on your current DS-2019?                         Yes*     No
*If yes, what is the expected date of departure?                           (Please include copy of visa stamps of J-1/J-2s who plan to travel.)

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
                                RELATIONSHIP                                                                                     COUNTRY OF
          MEMBER                                  DATE OF BIRTH                           COUNTRY OF          COUNTRY OF
                                   (spouse,                           CITY OF BIRTH                                                 PERM.
        (Family/Last,                              (mm/dd/yyyy)                             BIRTH             CITIZENSHIP
                                 daughter, son)                                                                                   RESIDENCE
     First/given, middle)




J-2 spouse’s e-mail address (if applicable):

3. Health Insurance:
The Department of State requires all J-1 Exchange Visitors and their accompanying dependents to have health
and accident insurance at the following minimum level of coverage:
    medical benefits of at least $50,000 per accident or illness
    repatriation of remains in the amount of $7,500
    expenses associated with medical evacuation in the amount of $10,000
    deductible not to exceed $500 per accident/illness

Information on Insurance Options
Insurance information can be found on the SISS website at http://siss.ucdavis.edu/health_j1.cfm Please review this
website for information on the cost of “premiums” (insurance payments) and health insurance companies in the US that
offer insurance to J-1scholars.

The insurance corporation underwriting the policy must have one of the following ratings:

            - -an A.M. Best rating of “A-” or above
            - -an Insurance Solvency International, Ltd., (ISI) rating of “A-i” or above
            - -a Standard & Poor’s Claims-paying Ability rating of “A-” or above
            - -a Weiss Research, Inc. rating of “B+” or above

Note: Insurance coverage backed by the full faith and credit of your home government meets these requirements.

U.S. government regulations require the University to notify the U.S. Department of State and to terminate J-1
exchange visitor status if they determine that the Exchange Visitor or family members willfully fail to comply with
the insurance requirements.
Agreement:
1.           I understand the health insurance requirements, and my responsibility to maintain the insurance
             coverage as stated above throughout my stay at the University of California, Davis.
2.           I understand that as an Exchange Visitor I am authorized to engage in the activity as noted in item #4 of
             the DS-2019, and agree to consult with SISS before making any changes in my program.
     Name:
                Family (Last)                                     Given (First)                              Middle

     Signature:                                                   Date:


     Name of UCD Department:
DS-2019 extension/rev. 11/15/11

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         Signature of Department              Date
              Chair                                    Chair



              Print or type name of Faculty            Signature of Faculty                     Date
              Sponsor                                  Sponsor

    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         Signature of Department              Date
              Chair                                    Chair



              Print or type name of Faculty            Signature of Faculty                     Date
              Sponsor                                  Sponsor

    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         Date
                                                       Physician

    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/

				
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