Training Internship Placement Plan Form DS Cultural Vistas

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					           Cultural Vistas | Training/Internship Placement Plan for Interns

                                                                                   U.S. Department of State
                                                                                                                                                                 *OMB APPROVAL NO. 1405-0170
                                                                                                                                                                 EXPIRATION DATE: 07-31-2009
                                            TRAINING/INTERNSHIP PLACEMENT PLAN                                                                                   ESTIMATED BURDEN: 60 minutes



Check one:              Occupational Field                                                                                                        Number of Years of Experience

     __   Trainee
                        Level of Degree                      Date Awarded (mm-dd-yyyy)                      Field of Study
         Intern

                                                                         PARTICIPANT INFORMATION
Trainee/Intern Name (Last, First, MI)                                                                       U.S. Residence Address

                                                                                                            To Be Determined

U.S. Telephone Number                                       FAX Number                                      Email Address

To Be Determined

                                                                     SITE OF ACTIVITY INFORMATION
Host Organization                                                                                           Address



Supervisor's Name (Last, First, MI)                                                                         Email Address


Phone Number                                                FAX Number                                      Supervisor's Title


Dates of Program (mm-dd-yyyy)                               Hours Per Week                                  Will Trainee/Intern receive a stipend?                 If so, how much?
                                                                                                                        Yes                 No
From:         To:                                                                                                                                                  $       per

                                                                            CONTRACT AGREEMENT
NOTE- Sponsors will not approve any contracts, and Trainees/Interns may not begin their programs until both a Training/Internship Placement Plan
(page 2) and proof of required insurance that meets 22 CFR 62.14 is on file with the sponsor.

Trainee/Intern- I hereby acknowledge, understand and agree to the attached Training/Internship Placement Plan.
Trainee/Intern Signature                                                                                    Date (mm-dd-yyyy)


Supervisor - I certify that I will provide on-site supervision and that this training/internship is known and approved by this company/business or
organization (site of activity). I will ensure that the required insurance is in place that meets 22 CFR 62.14 and provide the sponsor with written
evaluations of the trainee/intern's performance, including the number of hours performed, the type of training, and the quality of the performance. At
minimum, I will submit the evaluation at the mid-point and end of the program.
Supervisor's Signature                                                                   Date (mm-dd-yyyy)


Sponsor- I approve the attached Training/Internship Placement Plan. I certify the following:
1.        Sufficient planning, equipment, and trained personnel will be dedicated to provide the training/internship specified;
2.        The training/internship program is not designed to recruit and train aliens for employment in the United States;
3.        Trainees/Interns will not displace full-time or part-time U.S. employees; and
4.        That training and internship programs in the field of agriculture meet all requirements of the Employment Relationship under the Fair Labor
     Standards Act and the Migrant and Seasonal Agricultural Worker Protection Act (29 CFR Part 500).
I understand that false certification may subject me to criminal prosecution under 18 U.S.C. 1001, which reads: "Except as otherwise provided in this
section, whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly
and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or fraudulent
statement or representation; or makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent
statement or entry; shall be fined under this title or imprisoned not more than 5 years, or both."
Sponsor's Signature (RO/ARO)                                                                                Date (mm-dd-yyyy)


Program Sponsor Name                                                                                        Program Number

Cultural Vistas                                                                                             P-3-11157
                   *Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time required for searching existing data sources,
 DS-7002           gathering the necessary data, providing the information required, and reviewing the final collection. Persons are not required to provide this information in the absence
 04-2007           of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State
                   (A/ISS/DIR) 1800 G St. NW, Washington, DC 20520.
          Cultural Vistas | Training/Internship Placement Plan for Interns


Program Sponsor Name                                                             Program Number

Cultural Vistas                                                                  P-3-11157

                                                TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                 Field of Training/Internship



Name of Phase                                            Start Date for this Phase            End of Date for Phase

                                                                                                                          Phase         of
                                                               (mm-dd-yyyy)                       (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                     Page 2
           Cultural Vistas | Training/Internship Placement Plan for Interns

Program Sponsor Name                                                             Program Number

Cultural Vistas                                                                  P-3-11157

                                                TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                 Field of Training/Internship



Name of Phase                                             Start Date for this Phase           End of Date for Phase

                                                                                                                           Phase         of
                                                               (mm-dd-yyyy)                        (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                     Page 3
           Cultural Vistas | Training/Internship Placement Plan for Interns

Program Sponsor Name                                                             Program Number

Cultural Vistas                                                                  P-3-11157

                                                TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                 Field of Training/Internship



Name of Phase                                             Start Date for this Phase           End of Date for Phase

                                                                                                                           Phase         of
                                                               (mm-dd-yyyy)                        (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                     Page 4
           Cultural Vistas | Training/Internship Placement Plan for Interns

Program Sponsor Name                                                             Program Number

Cultural Vistas                                                                  P-3-11157

                                                TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                 Field of Training/Internship



Name of Phase                                             Start Date for this Phase           End of Date for Phase

                                                                                                                           Phase         of
                                                               (mm-dd-yyyy)                        (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                     Page 5
           Cultural Vistas | Training/Internship Placement Plan for Interns

Program Sponsor Name                                                             Program Number

Cultural Vistas                                                                  P-3-11157

                                                TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                 Field of Training/Internship



Name of Phase                                             Start Date for this Phase           End of Date for Phase

                                                                                                                           Phase         of
                                                               (mm-dd-yyyy)                        (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                     Page 6
           Cultural Vistas | Training/Internship Placement Plan for Interns

Program Sponsor Name                                                              Program Number

Cultural Vistas                                                                   P-3-11157

                                                 TRAINING/INTERNSHIP PLACEMENT PLAN
An acceptable Training/Internship Placement Plan should cover a definite period of time and should consist of definite phases of training or tasks
performed with a specific objective for each phase. The plan must also contain information on how the trainees/interns will accomplish those objectives
(i.e. classes, individual instruction, shadowing, etc.). Each phase must build upon the previous phase to show a progression in the training/internship. A
separate copy of page 2 must be completed for each phase if applicable (i.e.; if the trainee/intern is rotating through different departments).

Name of Trainee/Intern (Last, First, MI)                                                  Field of Training/Internship



Name of Phase                                             Start Date for this Phase            End of Date for Phase

                                                                                                                           Phase          of
                                                                (mm-dd-yyyy)                       (mm-dd-yyyy)
Specific Objective for This Phase




Skills to be Imparted for This Phase




Justification for On-The-Job Training




Chronology or Syllabus of Training or Tasks Performed During This Phase




Method of Evaluation and the Frequency of Supervision During This Phase




          DS-7002                                                                                                                      Page 7
Cultural Vistas | Training/Internship Placement Plan for Interns




Cultural Vistas Third Party Agreement
State Department regulations require that Cultural Vistas maintain an executed written agreement with
any third parties that outlines the relationship between Cultural Vistas and the third party on all matters
pertaining to the administration of the internship program. This agreement and the information
requested therein must be completed before Cultural Vistas will process an intern’s application
(issuance of Form DS-2019).

 Name of Trainee:                                                     Host Company:

 Compensation: Use estimated values for Room/Board and Transportation if exact values are not known

 $         Stipend per month           $         Room/Board per month $                    Transportation per month
 Contact Name:                                              Title:

 Phone:                                                     Fax:

 Email:                                                     Organization URL:

 Number of Employees in Organization:                       Number of Employees at Training Location:

 Number of Trainees/Interns at Training Location with J-1 Visa status:
 DUNS Number: (if available)                                Employer Identification Number (EIN):
 (Format: 99-999-9999)                                      (Format: 99-9999999)


     I certify that the applicant has been thoroughly screened for participation in my program.

     An interview was conducted:             In person               By videoconference               By web camera
         Telephone

     Please include a brief summary of the interview conducted evaluating their ability to undergo
     training in the United States:



     Name of Interviewer:                                   Date/Time of interview:
     Title:                                                 Signature:

        An interview was not conducted. (A Cultural Vistas representative or partner is required to
     conduct an interview if an employee of your organization has not.)
               Cultural Vistas | Training/Internship Placement Plan for Interns
This agreement refers to the structured practical training program for       (intern) to be undertaken at
(company/institution) within the framework of the prescribed Training/Internship Placement Plan (DS-7002).
Our organization agrees to the following conditions and regulations (please initial each statement):

         1) Cultural Vistas is the official Exchange Visa Sponsor, not the host company/institution, and assumes legal responsibility for the trainee/intern as
            it relates to visa law while the trainee/intern completes his/her program in the United States. Additionally, Cultural Vistas is responsible for
            participant selection and orientation, ensuring the participant has health and accident insurance that meets State Department requirements for
            the duration of the trainee’s program, and monitoring the participant’s program as required by the U.S. Department of State. The host
            company/institution assumes responsibility for abiding by all tax or labor laws and regulations, for maintaining a Workman’s Compensation
            Insurance Policy, as well as for abiding by all Federal, State, and Local occupational health and safety laws.
         2) We agree to act in accordance with U.S. Department of State regulations governing exchange visitor trainee/intern programs. These regulations
            are available for review at http://exchanges.state.gov/ under “J Exchange Program.”
                       The primary objective of training is to enhance the exchange visitor's skills in his or her specialty occupation through participation in a
                        structured training program, as outlined in the Training/Internship Placement Plan, and to improve the participant's knowledge of
                        American techniques, methodologies, or expertise within the individual's field of endeavor.
                       We agree to provide the participant with appropriate equipment, supervision, and evaluation during the training period. We will
                        notify Cultural Vistas in advance of any changes to the intended training plan including, but not limited to, the training location,
                        training content, duration of training, and financial support. Furthermore, dismissal or termination of the trainee/intern must be
                        reported to Cultural Vistas immediately.
                       Any training undertaken by the trainee/intern may not displace an American employee or fill a labor shortage. We certify that it is not
                        our intent to train this person for future employment in the U.S.

         3) If the trainee/intern meets all eligibility requirements, Cultural Vistas will issue the Certificate of Eligibility (Form DS-2019) required for the visa
        application. The U.S. consulate or embassy will make the final determination whether to issue the J-1 Exchange Visitor visa. Cultural Vistas has no
        power to influence either a positive or negative decision on a participant’s behalf.

         4) If the trainee/intern receives funding, either in whole or in part, directly or indirectly, from the U.S. government or his/her home government,
        the individual will be subject to the two year home residency requirement and will not be allowed to enter the U.S. after completing his/her
        program on an H, L, or Lawful Permanent Resident status for a period of two years.

         5) The trainee/intern may only undertake training at the host company according to the dates on the DS-2019 form. The trainee/intern is expected
        to leave the U.S. upon completion of the training (within 30 days) or dismissal from the program (within 10 days) and return to his/her home
        country.

         6) The trainee/intern is required to submit his or her local contact information (home address, home and company phone) within three weeks of
        arriving in the U.S and should his/her address change during the program, new contact information must be provided to Cultural Vistas within one
        week.; failure to do so will result in the termination of the participant’s program.

         7) We must submit an intermediate and final evaluation of the trainee/intern to Cultural Vistas. The trainee/intern is required to submit a midterm
        and final report to Cultural Vistas; failure to do so will result in the termination of the participant’s program.

         8) We understand that the trainee/intern takes part in his/her program in the U.S. at his/her own risk and of his/her own volition. Cultural Vistas
        cannot be held liable under American or the participant’s home country’s law for any damage or injury; in particular injury to persons or damage to
        property, suffered by or caused by the trainee/intern, during the course of the program.

         9) We understand that Cultural Vistas undertakes a variety of activities to adequately prepare participants, including, but not limited to,
            information on health and safety issues, insurance issues, housing and accommodation, visa and residency requirements, political and cultural
            conditions, roles and responsibilities of partners and host companies, and laws specific to the U.S. Beyond this preparation, a range of issues
            related to a participant’s experience is beyond the control of Cultural Vistas. Cultural Vistas cannot:
                Guarantee the safety of participants or eliminate all risks from the participant’s environment while in the U.S.;
                Prevent participants from engaging in illegal, dangerous or unwise activities;
                Assume responsibility for the actions of persons not employed or otherwise engaged by Cultural Vistas, for events that are not part of the
                 program, or that are beyond the control of Cultural Vistas and its subcontractors, or for situations that may arise due to the failure of a
                 participant to disclose pertinent information.

I hereby attest that I have read and understood the information given above and that the information provided in the Training/Internship Placement Plan
and in the enclosures is true and complete.

Signature _______________________________________________________________________ Date Tuesday, October 23, 2012

Name (Printed)

Title

				
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