GLOBAL ACADEMIC SERVICES

PART I: DS-2019 DEPARTMENT REQUEST FORM

STUDENT INTERNSHIP CATEGORY
CERTIFICATE OF ELIGIBILITY) (22 CFR 62 Exchange Visitor Program)
DEPARTMENT INSTRUCTIONS
Global Academic Services (GAS) serves as a program sponsor for the J-1 Exchange Visitor Program on behalf of
Florida Atlantic University (FAU). GAS advises FAU departments on appropriate visa classifications for
prospective international visiting scholars in the categories of professor, research scholar, short-term scholar,
specialist, or international student intern.
HOST DEPARTMENT INSTRUCTIONS:
• Submit your request electronically to [email protected]
• All requests must be submitted at least 60-90 days before the expected start date. Please allow 10 business days for
processing.
• Please provide the Exchange Visitor with Part II -Exchange Visitor DS-2019 Application Request Packet to the visitor
to complete.
• As the Host Department, please review all responses in sections of the Part II of the packet, and collect all required
supporting documentation such as passports, proof of funding, CV, Notification of Insurance, etc.
• Host Departments must complete Part I - DS-2019 Department Request Form for Internship and collect all approval
signatures.
• Background checks - Departments are responsible for completing a background check on all exchange visitors,
whether they are paid or unpaid. Departments should send an email to [email protected] and include the Exchange
Visitor’s full name (as it appears in the passport), email address, and the index account to be charged. Departments
must notify Global Services if the exchange visitor is not cleared to start the program.
• Departments are responsible for informing Global Services of any significant changes in the Exchange Visitor’s
program (for example: funding sources, research objective, additional job responsibilities which are significantly
different from the initial assignments).
• Department must notify GAS if the Exchange Visitor departs prior to the program completion listed on DS-2019.
• For non-paid Exchange Visitors, Departments should complete the Scholar and Intern Personnel Form to request a Z
number, email address, and access to obtain an Owl card.

DOCUMENT CHECKLIST
 Complete Part I and Part II DS-2019 Request Packet
 Complete DS-7002 Form
 Copy of invitation/offer letter from the host department
 Academic Status Certification Form
 Interview Report Form
 Applicant’s Resume/CV
 Proof of language proficiency
 Proof of sufficient funding in English and US Dollars
 Copy of passport biographical pages for the applicant and dependent(s)
 Signed Notification of Insurance Form
 Deemed Export Control Clearance Memo
o Submit "Deemed Export Visa Application" by email to [email protected]
o You will receive a Deemed Export Control Memo from Myles Lathrop via email.
o Submit the “memo” with this packet.

1 Part I: Internship DS-2019 Department Request Form 07/27/2022

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL SERVICES SERVICES
PART I
SECTION A - DS-2019 DEPARTMENT REQUEST FORM
STUDENT INTERNSHIP CATEGORY

To be completed by Host Department

U.S. DEPARTMENT OF STATE REGULATIONS FOR INTERNSHIP EXPERIENCE:
• Interns must be currently enrolled and pursuing studies at a post-secondary academic institution outside the U.S., or
must have graduated from such an institution within 12 months prior to the proposed internship start date.
• Internships are up to 12 months in length without the possibility of extension beyond this period.
• Upon completing the internship program, participants must return to their home country and resume (if applicable)
their academic programs in order to graduate from the post-secondary institution outside the U.S.
• The internship experience must be at least 32 hours per week with no more than 20 % of the total activities
consisting of clerical work.
• The program must provide the participants with opportunities to expand upon existing knowledge and skills, and
must expose participants to American techniques, methodologies, and expertise.
• The program must not duplicate the participant’s prior work experience or training received elsewhere.
• Internships may not involve child care, elder care, clinical/medical care, or aviation.
• Additional requirements exist for Hospitality/Tourism and Agriculture-related internships.
• Interns must have on-site supervision in completing daily tasks related to their internship activities.
• Interns must be evaluated at least once every six months. All evaluations must be completed and signed by the host
faculty prior to the conclusion of the internship program. Copies of the evaluations must be submitted to the Office
of Immigration Services and Compliance.

Exchange Visitor’s Name:

INTERNSHIP START DATE MUST BE 60 -90 DAYS FROM PAPERWORK SUBMISSION

Internship Start Date: Internship End Date:
Host Faculty First Name: Host Faculty Last Name:
Faculty Email: Faculty Phone Number: __________________________________
Administrative Contact Name: __________________Administrative Contact Email: _____________________________
Administrative Phone Host Department Name/College: _________________________
Name of Primary Site of Activity: ______________________________________________________________________
Address of Primary Site Activity: ______________________________________________________________________
Visitor’s field of specialization (specify chemistry, physics, etc.):
Total hours per week (min. 32 required): _________ Hours of clerical activities per week: __________
Will this internship include any child care, medical patient care, aviation, or unskilled labor: ___ Yes* ____ No
*Activities listed above are not permitted under the Exchange Visitor Program.
*If you answered “yes”. Please contact the Office of Immigration Services and Compliance.
Description of Internship at FAU:

2 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES
PART I
SECTION C – FINANCIAL INFORMATION
To be completed by Host Department

Estimated Expenses Exchange Exchange Visitor Exchange Visitor Exchange Visitor with
(housing, food, insurance, Visitor with Spouse with Spouse and Spouse and Two or
transportation, etc.) One Child More Children
Monthly Estimated Living Expenses $2,000 $2,200 $2,500 $2,800
Yearly Estimated Expenses $24,000 $26,400 $30,000 $33,600

Proof of funds must be submitted with application.

Review this financial section carefully and check the appropriate category U.S. Dollar Amount
_____Salary from Florida Atlantic University. May include grant funds
FLORIDA ATLANTIC that are NOT specifically for international educational or cultural $___________
UNIVERSITY SALARY exchange. ____Month ___Annual

_____Salary from Florida Atlantic University. May include grant funds $___________
that are SPECIFICALLY for international educational or cultural exchange.
____Month ___Annual
$___________
*PERSONAL FUNDS _____Personal Funds from the Exchange Visitor
____Month ___Annual
**DIRECT FUNDING U.S. Government Agency:
FROM GOVERNMENT International Organization: $___________
OR INTERNATIONAL Exchange Visitor’s Government:
ORGANIZATION Binational Commission of Visitor’s Country: ____Month ___Annual
Other Organization:

*Individuals who are funded completely through personal funds must have ties with a research institution or university abroad, must have
written permission from the home institution for the period of the DS-2019 request, and may only receive a DS-2019 for up to 12 months.

**If funding is from a source other than FAU, a letter or other document from the funding source confirming the source, amount in U.S.
dollars, and dates of funding must accompany this request. Foreign language documents must be accompanied by a certified English
translation.

3 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES

BACKGROUND CHECKS ON EXCHANGE VISITORS

FAU HOST DEPARTMENT INSTRUCTIONS: Background checks are the responsibility of the FAU Host
Department. For background checks that are in progress, the FAU Host Department must notify
the Office of International Employee and Scholar Services if the background check does not meet
company standards. To initiate a background check, please email your request to [email protected].
30TU U30T

Check one of the below and provide the date of the background check:

In Progress - The FAU Host Department has requested a background

check with Human Resources, and the background check is still in
PROGRESS. The FAU Host Department is responsible for notifying the
Office of International Employee and Scholar Services if the background
check does not meet company standards.

Provide date of when the background check was requested by the FAU
Host Department (For in progress background checks only).

__________________________________________________________

Completed - The FAU Host Department has requested a background

check with Human Resources, and the background check results meets
company standards.

Provide date of when the background check was completed by Human

Resources.

4 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES
PART I
SECTION D – DEEMED EXPORT CONTROL CHECK

Department Instructions: Complete the “Visa Applicant Export Control Questionnaire for Sponsored & Non-
Sponsored Activities” form and submit it to Florida University’s Export Control Officer, Myles Lathrop, via email.
Once the check is completed, please forward the “confirmation memo” with this packet.

Link to Form: https://www.fau.edu/research-admin/export-control/files/deemed-export-questionnaire-visas-

and-visitors.pdf
Link to Government Regulations: https://www.bis.doc.gov/index.php/policy-guidance/deemed-exports/deemed-
exports-faqs

Bureau of Industry and Security/ U.S. Department of Commerce: Any foreign national is subject to the deemed
export regulations except a foreign national who (1) is granted permanent residence, as demonstrated by the
issuance of a permanent resident visa (i.e., Green Card); or (2) is granted U.S. citizenship; or (3) is granted status
as a protected person under 8 U.S.C. 1324b(a)(3). This includes all persons in the U.S. as tourists, students,
business people, scholars, researchers, technical experts, sailors, airline personnel, salespeople, military
personnel, diplomats, etc.

NAFSA: Activities of non-immigrants on campus may come under the purview of several kinds of export
control regulations:
• The Department of State's International Traffic in Arms Regulations (ITAR) regulate the transfer and
export of technologies relating to military applications listed on the Munitions Controls List (MCL).
• The Department of Commerce's Export Administration Regulations (EAR) regulate the transfer and
export of technologies relating to civilian applications listed on the Commerce Control List (CCL).
• The U.S. Department of Treasury's Office of Foreign Assets Control (OFAC) regulates restrictions created by
trade embargoes.
Technology or source code is considered to be exported not only under the traditional sense of shipping it
overseas; an export of technology or source code can also be "deemed" to take place when it is released to a
foreign national within the United States. Deemed exports must be authorized through an export license issued by
the responsible Government agency.

Technology or code is considered "released" for export when it is "available to foreign nationals for visual
inspection (such as reading technical specifications, plans, blueprints, etc.); when technology is exchanged
orally; or when technology is made available by practice or application under the guidance of persons with
knowledge of the technology." Many activities at colleges and universities can benefit from several exclusions
to the export license requirement, including a fundamental research exclusion, an education exclusion, and a
public domain exclusion

Part of a college or university's institutional responsibility is to determine if an export license must be

sought for particular activities.

Florida Atlantic University: FAU is committed to complying with all United States export control laws and
regulations. These laws and regulations were created and implemented by agencies including, but not limited to,
the Department of Commerce (Export Administration Regulations - EAR), the Department of State (International
Traffic in Arms Regulations – ITAR), and the Department of the Treasury (Office of Foreign Assets Control – OFAC).
http://www.fau.edu/research/export-control/index.php

5 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES
DS-2019 EXTENSION REQUESTS ONLY

HOST DEPARTMENT INSTRUCTIONS: If you are requesting an extension of the program

dates for a current scholar/intern with a valid DS-2019, please review the latest FAU Visa
Applicant Questionnaire form that you submitted to conduct the latest Deemed Export Control
Check that FAU has on file.

If the information that was previously submitted to conduct the latest Deemed Export Control
Check on file has changed, you will be required to submit a new FAU Visa Applicant
Questionnaire form and have a new Deemed Export Control Check conducted.

If the information that was used to conduct the latest Deemed Export Control Check on file has
not changed, then please complete the bottom portion of this form.

NO CHANGES TO THE FAU VISA APPLICANT QUESTIONNAIRE FORM

With respect to any and all information previously submitted for

________________________________________________ (APPLICANT’S NAME). This
confirms that the information previously provided to conduct the latest Deemed Export Control
check on file with FAU remains accurate, true, complete and has not changed since the last
deemed export control check. The information on the FAU Visa Applicant Questionnaire that
was previously submitted to the Division of Research does not require any correction, edit,
modification, or amendment.

Print Name of Faculty Sponsor: ______________________________

Signature of Faculty Sponsor: ________________________________

Date of Signature: _________________________________________

6 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES
PART I
SECTION E – VERIFICATION OF LANGUAGE PROFICIENCY (22 CFR 62.10 (2))
The U.S. Department of State expects exchange visitors to have a level of English language proficiency that allows
them to successfully perform their scholarly activities, to navigate daily life in the US, to read and comprehend
program materials, understand their responsibilities, rights, and protections, and to obtain assistance when
necessary.
Name of student:_____________________________________________________________________________
English proficiency can be documented through one of the following options:

1. Skype interview in English with the prospective Exchange Visitor on date: / /

Acknowledgment: I certify that I conducted an interview in English with the prospective Exchange Visitor and
his/her English language skills are sufficient for effective day-to-day functioning in the internship environment
and for participation in university and community life.

Host Faculty Member’s Name Signature Date

2. ___ A certified English teacher

Acknowledgment: I am/was this prospective intern’s English teacher from _____________ to ________________.
Month/day/year Month/day/year

Acknowledgment: I certify that the student’s language skills are sufficient for effective day-to-day functioning in the
internship environment.

English teacher’s name English teacher’s signature Date

Email address Telephone Number Fax Number

3. One of the following standardized language proficiency tests was completed (attach copy of test results):

TOEFL Written (score) Minimum score required is 500.

TOEFL Computer-based (score) Minimum score required is 173.

TOEFLI Internet-based (score) Minimum score required is 61.

IELTS (score) Minimum score required is 6.0

The minimum scores listed above are the same minimum scores required for admission at FAU.

Note: Attach a copy of the test results. Results are valid for two years from the test date.

7 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL ACADEMIC SERVICES
PART I
SECTION F – ADDITIONAL ELIGIBILITY QUESTIONS
NON-PAID EXCHANGE VISITORS ONLY
The information below is necessary in order to determine J-1 status eligibility and to ensure that exchange visitors will
be able to successfully complete their academic objectives. Please answer all questions:

1.____Yes ____No
The exchange visitor will be engaged primarily in collaborative research with other FAU faculty and researchers.
2.____Yes ____No

The exchange visitor has written leave permission from the home institution for the entire period requested
through this document.

3.____Yes ____No
The inviting department will restrict access to sensitive research and materials and will follow university export
control regulations.

4. The exchange visitor will receive a courtesy/affiliate appointment. Yes No

If you answered “no” to item #4, please check type of support that the host department will provide to this exchange
visitor: FAU Email Account FAU OWL Card ___Library Access Access to office computer
Access to office phone ___Office space

5.The exchange visitor will spend the majority of his/her research time at a physical location within FAU.
Yes No**.
If you answered “no” to item #5, please provide a brief description of where the visitor will be located during the period
of J-1 sponsorship:

6. The exchange visitor will be engaged primarily in independent research without student contact (DS-2019s will only be
issued for a maximum of 12 months if permitted by the circumstances). Yes No**

**If you answered “no” to question #5 and question #6, you must submit Volunteer Registration Form and the Volunteer
Waiver Release Form in compliance with the University Policy for Volunteers (Regulation 6.1). These forms must be
submitted at least 15 days in advance of the program start date.
o Volunteer Registration Form
o Volunteer Waiver and Release

Note: A university background check is required for non-paid J-1 exchange visitors who fall under the Category One
volunteer definition. The cost of the background check be covered by the host department or may be charged to the
Exchange Visitor. Background check costs vary (estimated range: $60 to $200). Departments are responsible for making
their own arrangements to collect the background check fee from the Exchange Visitors Please send an email to
[email protected] to request a background check.

8 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL SERVICES SERVICES

PART I
SECTION G – INTERVIEW REPORT FORM

This form is a required part of the application process for the Intern category under the J Exchange Visitor
Program. The form must be completed and signed by the host faculty member at Florida Atlantic
University. If a written agreement exists between FAU and the prospective intern’s home institution, the
form may also be signed by a representative from the intern’s home university.
1. Name of Student
2. The student was interviewed by
(Name)
3. Interviewer’s position: Host Faculty at FAU
Representative from intern’s home institution (attach copy of the
written agreement between FAU and home institution)
4. Interview was completed on
Month/Day/Year
5. The interview was completed (check appropriate choice):
In person By telephone By video/web camera
6. Explain how the internship relates to the intern’s current or recently completed studies:

7. Does this person have the adequate academic preparation for the proposed internship?
Yes No
8. Explain what specific skills and knowledge the intern will be able to gain from this internship, and
how this internship differs from the intern’s previous internship or training experiences.

9. Interviewer’s signature Date: ___________________

If the interviewer is from the university abroad, place official university seal or stamp here.

9 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
GLOBAL SERVICES SERVICES
PART I
SECTION H – DEPARTMENT APPROVAL
Please review this information carefully before signing the form.

The U.S. Department of State (Bureau of Educational and Cultural Affairs) administers and monitors the J Exchange
Visitor Program. According to program regulations, all J Exchange Visitors and their accompanying dependents must
be familiar with the rules and regulations governing the program and must comply with the mandatory medical
insurance requirements.

IMMIGRATION REPORTING REQUIREMENTS (22 CFR 62.15)

Global Academic Services is required to maintain J-1 records in the SEVIS database and to ensure compliance with
all immigration requirements pertaining to the Exchange Visitor Program.

Due to the time-sensitive nature of these requirements, Host Departments must:

• Ensure that Exchange Visitors contact GAS upon arrival for check-in and a brief orientation (to be completed
within 10 days of arrival in the U.S.).
• Notify Global Services if the Exchange Visitor expects to arrive after the start date listed on the DS-2019.
• Notify Global Services of the Exchange Visitor’s departure date (prior to the individual’s departure).
• Notify Global Services of any events that may interfere the Exchange Visitor’s successful progression and
completion of the program.
• Ensure activities fall within the primary program objective for which the Exchange Visitor’s DS-2019 was issued.
Notify Global Services within 10 days of any changes to the Exchange Visitor’s mailing address, email, or phone
number.

INSURANCE REQUIREMENT (22 CFR 62.14)

Sponsors must require that all exchange visitors have insurance in effect that covers the exchange visitors for sickness
or accidents during the period of time that they participate in the sponsor’s exchange visitor program. In addition,
sponsors must require that accompanying spouses and dependents of exchange visitors have insurance for sickness
and accidents. Sponsors must inform all exchange visitors that they, and any accompanying spouse and dependent(s),
also may be subject to the requirements of the Affordable Care Act. A willful failure to carry insurance is a violation
of the Exchange Visitor Program regulations. DOS treats willful failure to carry insurance as a serious infraction for
which neither correction of the record nor reinstatement are available as remedies.

I hereby certify that the information provided in the Department Request for DS-2019 application is true and correct
to the best of my knowledge. I reviewed the information and I understand the college and departmental
responsibilities of hosting this prospective exchange visitor.

Sponsoring Faculty Member (Print Name) Signature Date

Chair/Director (Print Name) Signature Date

Dean (Print Name) Signature Date

10 Part I: Internship DS-2019 Department Request Form

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11 Part I: Internship DS-2019 Department Request Form

 FLORIDA ATLANTIC UNIVERSITY
J-1 STUDENT INTERN EVALUATION FORM
Purpose: The Department of State requires that the hosting FAU Faculty/Supervisor evaluate the progress and
performance of the J-1 Student Intern prior to the completion of the internship (22 CFR 62.22(f)(2)(iv))

Instructions: Hosting FAU Faculty/Supervisor must complete an evaluation at the (a) mid-point and at the (b)
end point of a student intern’s program. For internships less than 6 months, only one (1) final evaluation is
required. For internships 6 months and longer, a mid-point evaluation and a final evaluation is required. A
copy of the evaluation(s) must be submitted to the Global Academic Services and kept in the student
intern’s file for at least 3 years following the completion of each intern’s program. Please submit the
completed and signed Student Intern Evaluation Form to [email protected].

EVALUATION TYPE: _______ Mid-Point Evaluation ______ Final Evaluation

STUDENT INTERN INFORMATION:

Last Name: _____________________________________________________________________________

First Name: _____________________________________________________________________________
SEVIS #: N_________________________________ Email:________________________________________

INTERNSHIP INFORMATION:

Host Department/College Name: _______________________________

Internship Start Date: _____/______/______ Internship End Date: ______/______/______

HOST FACULTY/SUPERVISOR CERTIFICATION:

Host Faculty/Supervisor Last Name: _________________________________________________________

Host Faculty/Supervisor First Name: _________________________________________________________
Position Job Title: ________________________________________________________________________
FAU Email Address: _______________________________________________________________________

Evaluate the J-1 student intern’s performance based on the goals and objectives outlined on the DS-7002
Training and Internship plan. Please review the DS 7002 before answering this question.

________ Excellent _______ Above Average _______ Average _______ Below Average

Rate the overall student intern and training experience:

________ Excellent _______ Above Average _______ Average _______ Below Average

12 Part I: Internship DS-2019 Department Request Form

Host Faculty/Supervisor Feedback:

Supervisor’s Print Name: Supervisor’s Signature: Date:

STUDENT INTERN CERTIFICATION:

How would you rate the overall training program at Florida Atlantic University, and its educational benefits to you?

________ Excellent _______ Above Average _______ Average _______ Below Average

Please rate the overall training program and its benefits:

________ Excellent _______ Above Average _______ Average _______ Below Average

Please provide feedback on your internship experience:

Student Intern’s Name Student Intern’s Signature Date

13 Part I: Internship DS-2019 Department Request Form 07/27/2022