Section 4 to be completed by KSU Hosting Department. Be sure to type or print clearly

Section 4: Department Information and Approval

Dates of Intended Sponsorship
through
Professor
Research Scholar
Short-Term Scholar (up to 6 months
KSU Department
J-1 Host’s Name

KSU Department: ________________ J-1 Host's Name: ________________ Email: ________________ Phone Number: ________________ Type of Supervisor: ☐Direct (close supervision) ☐Indirect (will work independently) Is the proposed visitor a relative or family member of the hosting faculty member? No ☐ Yes ☐

Phone Number
Email
Indirect (will work independently
Direct (close supervision
undefined
Yes

Required Documentation to be Submitted with this Form

Original Invitation Letter to Visitor
Detailed Description of Activity, which describes what the visitor will be doing while at KSU
All required signatures
Proof of English Language Proficiency

By signing below, we attest that we will comply with the following responsibilities in hosting a J-1 visitor:

  1. The department agrees to host the scholar included on this form as a J-1 Exchange Visitor and have re3ad and understand the host responsibilities outlined on page 3.
  2. The department will have the J-1 Exchange Visitor (and any accompanying dependents) make an appointment to check in with OGSIA by the first day of his/her appointment so that OGSIA can fulfill SEVIS reporting requirements.
  3. If the exchange visitor decides to not come to KSU or will be delayed in arriving, the department will inform OGSIA as soon as possible.
  4. The department understands that all J-1 Exchange Visitors and their J-2 dependents are required by Kentucky State University and the U.S. Department of State to be covered by health insurance.

Required Signatures: Hosting Faculty Member: ________________ Date: ________________

Department Chair: ________________ Date: ________________

Hosting Faculty Member
Date
Department Chair
Date
Dean
Date
HR Officer
Date