Part 1: Department Information College supporting this exchange request Department Administrative contact name Administrative contact phone Administrative contact email Faculty sponsor name Faculty sponsor title Faculty sponsor email Faculty sponsor phone Part 2: Visiting Faculty/Staff (Exchange Visitor) Information Last name (family name) First name (given name) Length of stay - from: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 to: Year Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Proposed exchange visitor category - None -Professor (minimum of three weeks/maximum of five years)Research Scholar (minimum of three weeks/maximum of five years)Short-Term Scholar (maximum of six months)Specialist (maximum of one year) Will the visitor require access to a lab? Yes No Will the visitor supervise other employees? Yes No Site of activity Department Name: Street: City: State: Zip code: Is the funding obtained from a U.S. Govt. Agency to support this exchange? Yes No Name of Funding Agency Provide the name of the agency that has supplied your funding. Funding Amount Provide the amount of funding supplied by this agency. Is HSU providing the funding for the exchange? Yes No Is this a faculty paid position? - None -YesNo Funding Amount from HSU Provide the amount of funding supplied by HSU Type of funding What is the type of funding? (e.g., grant/stipend) Does the exchange visitor have funding from their gov't or university? Yes No Funding Amount Source Provide the source of the funding. Amount of Funding Provide the amount of this funding. Description Please provide a detailed description of the exchange visitor's program activity, including proposed teaching/research project, cultural programming, and expectation of results. Part 3: English Language Proficiency English Language Test Has the exchange visitor demonstrated English language proficiency? English language proficiency can be demonstrated by meeting the undergraduate language requirements. - None -YesNo Signed documentation Does the exchange visitor have signed documentation attesting to English language proficiency? English language proficiency can be shown by providing information from a U.S. or foreign institution where English is the/an official language in the form of a letter or official transcript from an accredited college or university verifying either full time enrollment in a post-secondary degree program or completion of a degree program (e.g., a bachelor’s degree). - None -YesNo Interview Has an interview been conducted with the exchange visitor? The interview can be conducted in-person, by video-conferencing (e.g., Skype), or by telephone. Please complete the below Interview Verification Form following the interview. - None -YesNo Part 4: Checklist of Sponsor's Responsibilities Checklist I will inform International Programs and Services within 72 hours if the Exchange Visitor is unable to come to Humboldt. I have arranged assessment for the Exchange Visitor’s English proficiency and can confirm that the scholar possesses sufficient English language proficiency to “successfully participate in his or her program and to function on a day-to-day basis” in accordance with 22 CFR 62.10(a)(2). I will ensure the exchange visitor is on campus" for at least 75% of the Exchange Visitor’s visit. I understand that the Exchange Visitor must conduct his/her program activity at the location(s) listed on the Form DS-2019. I will ensure that the Exchange Visitor will (a) report to the Center for International Programs within three business days of his/her arrival and (b) complete the federally mandated orientation with one calendar month of arrival. I will monitor the Exchange Visitor’s progress and report any extended absences or program changes to International Programs and Services (e.g., if the Exchange Visitor completes his/her program before the scheduled end date of the program as stated on the DS-2019). I understand that if the sponsored scholar is not performing to the level agreed upon, I am to contact International Programs and Services. I understand that federal law restricts the sharing of certain technologies and software with foreign nationals. These rules are complex and substantial penalties may be imposed for violations. If the scholar may have access to export controlled technology or software controlled by federal law, I will contact the Office of Risk Management. I understand that if the Exchange Visitor does not maintain the federally mandated level of health insurance coverage s/he will be out of status and his/her program will be terminated. I will assist the Exchange Visitor and his/her family to learn of and participate in social, cultural, and professional activities during their stay at HSU. Signature Electronic signature Please click the checkbox below to electronically sign this form.