Forms | UCLA Med School

GENERAL FORMS	DESCRIPTION	WHO MUST COMPLETE
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P39 Recharge Form – Visa and Licensing Office P39 Recharge Form – DCISS	Recharge Forms (formerly P39)	All departments requesting services from the DGSOM Visa and Licensing Office.
DGSOM Visa and Licensing Fee Structure	Summary of the Recharge Fee for Visa and Licensing Office	Department Coordinators These are the most current fees for Visa and Licensing Services.

J-1 Exchange Visitors Forms	DESCRIPTION	WHO MUST COMPLETE
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J-1 Initial Request Checklist J-1 Extension Request Checklist J-1 Amendment Request Checklist J-2 Separate Entry Request Checklist	Guide on what needs to be completed and submitted for specific J-1 requests.	Department Coordinators The department coordinator must submit together with the DS-2019 Request and other supporting documents.
Certification of English Proficiency	The Department of State requires J-1 Exchange Visitors to have “sufficient proficiency in the English language as determined by an objective measurement of the English language, proficiency to successfully participate in his or her program, and to function on a day- to-day basis.”	Department Coordinators The certification of English proficiency must be submitted together with the DS-2019 request and other supporting documents. This form is required for all “Initial” and “Transfer In” requests
J-1 Physicians Scholars	The form must be completed if the incoming exchange visitor is a foreign physician participating in UCLA’s J-1 exchange visitor program.	Faculty Sponsor The department coordinator must submit together with the DS-2019 Request and other supporting documents.
J-1 Early Program Completion Form	This form is needed when the scholar is ending their program more than 15 days prior to their current DS-2019 end date.	Department Coordinators The department coordinators must submit the early J-1 program completion form to the VisaAndLicensing@mednet.ucla.edu
J-2 Dependent Information Form	This form is submitted by the Exchange Visitors to add legal spouse and/or unmarried minor child (under 21 years of age) to the J-1 SEVIS record.	Exchage Visitors All requests must be returned to the Department Visa Coordinators together with the required supporting documents.

EXCHANGE VISITOR SUPPLEMENT QUESTIONNAIRES	DESCRIPTION	WHO MUST COMPLETE
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Exchange Visitor Supplement Questionnaire – Initial Request Exchange Visitor Supplement Questionnaire – Extension Request Exchange Visitor Supplement Questionnaire – Separate Entry J-2 DS-2019 Request	The Exchange Visitor Supplement Questionnaires are intended for the exchange visitors to complete to provide the required additional information to their host departments to submit the corresponding DS-2019 requests The forms also serve as an attestation of the exchange visitors J-1 regulation eligibility and compliance. The request must be submitted to the Visa and Licensing Office together with the all required supporting documents for the J-1 Requests.	Exchange Visitors All requests must be returned to the Department Visa Coordinators together with the required supporting documents.

ADDRESS AND CONTACT INFORMATION	DESCRIPTION	WHO MUST COMPLETE
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Address and Contact Information Update Form	J-1 Exchange Visitors are required to update the scholars address with the DGSOM Visa and Licensing office within 10 days of changing residence.	Exchange Visitors The update must be submitted to the VisaAndLicensing@mednet.ucla.edu through the Department Visa Coordinators.

EMPLOYMENT REQUEST	DESCRIPTION	WHO MUST COMPLETE
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J-1 Off Campus Activity Request Form	This form is needed to request approval from the DGSOM Visa and Licensing Office to engage in off-campus employment. This employment is limited to short-term consultations and occasional lectures per U.S. government regulations.	Exchange Visitor and Host Department The request form must be submitted to the DGSOM Visa and Licensing Assistant Director directly. If the activity involves remuneration or travel reimbursement, 2 letters will be required from your UCLA faculty supervisor and organization where the activity is taking place.

TRAVEL AUTHORIZATION	DESCRIPTION	WHO MUST COMPLETE
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DS-2019 Travel Signature Request Form	This form is needed to request official DS-2019 travel validation to re-enter from a trip outside the U.S.	Exchange Visitor Submit the DS-2019 travel signature request form to: VisaAndLicensing@mednet.ucla.edu
J-1 Out of Country Request Form	This form is used by J-1 scholars who will continue to pursue their J-1 program objectives while they are outside of the U.S. for more than 30 days but less than one year.	Department Coordinators The department coordinator must submit the form to: VisaAndLicensing@mednet.ucla.edu

TRANSFER	DESCRIPTION	WHO MUST COMPLETE
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Inter-Department Transfer Form	Exchange Visitors may be authorized to change departments as long as there are no major changes in the EV’s initial research objectives at UCLA.	Department Coordinators The department coordinators must submit together with the DS-2019 Request Form and appropriate Recharge Forms.
J-1 Exchange Visitor Transfer-In Form	This form must be completed if the J-1 scholar intends to transfer their program from another accredited institution within the U.S. to DGSOM.	Incoming EV and current ARO/RO The form must be submitted together with the DS-2019 Request Forms and other supporting documents.

MANDATORY CHECK-IN	DESCRIPTION	WHO MUST COMPLETE
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Exchange Visitor Contract J-1 Visitors Check-in and Arrival Information	These forms must be completed by the exchange visitor and submitted to their host department during their mandatory checking-in appointment.	Exchange Visitors The department coordinators must forward the check-in forms and required documents to the DGSOM Visa and Licensing Office within 25 days of the scholar’s arrival.

H-1B Temporary Specialty Occupation Worker	DESCRIPTION	WHO MUST COMPLETE
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Request for H-1B Sponsorship	For initial, extension, and amendment requests for Specialty Occupation Workers that are submitted to DCISS.	Department Coordinators The department coordinators must initiate an H-1B Action in VITS for records and reports keeping and must send this form to Joan Cerera.

O-1 Extraordinary Ability	DESCRIPTION	WHO MUST COMPLETE
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O-1 Request for Eligibility Review	For initial O-1 Application. This form is used to request DGSOM Visa and Licensing Office and the Outside Counsel to review a prospective or current UCLA employee’s eligibility for O-1 Extraordinary Ability.	Department Coordinators Please complete and email to JCerera@mednet.ucla.edu together with a copy of the Foreign National’s most recent CV. Do not include recharge form (P39).
O-1 Department Sponsorship Request Form	This form is used to request for the DGSOM Visa and Licensing Office to file an O-1 petition for a prospective or current employee at UCLA.	Department Coordinators Once the O-1 eligibility determination has been conferred by the Visa Office Assistant Director, the department coordinators must initiate an O-1 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the required documents and the Visa Office Recharge Form.
Letter of Request for O-1 Sponsorship	Letter Template from the Department Chair justifying the need to fill the position and how the Foreign National will benefit UCLA.	Department Coordinator signed by the Department Chair This letter must be submitted together with the O-1 Department Sponsorship Request Form

Permanent Residence	DESCRIPTION	WHO MUST COMPLETE
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PR Request for Eligibility Review	For PR Sponsorship. This form is used to request DGSOM Visa and Licensing Office and the Outside Counsel to review a prospective or current UCLA employee’s eligibility for PR sponsorship.	Department Coordinators Please complete and email to JCerera@mednet.ucla.edu together with a copy of the Foreign National’s most recent CV. Do not include recharge form (P39).
PR Department Sponsorship Request Form	This form is used to request for the DGSOM Visa and Licensing Office to file a PR Sponsorship for a prospective or current employee at UCLA.	Department Coordinators Once the PR eligibility determination has been conferred by the Visa Office Assistant Director, the department coordinators must initiate a PR Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the required documents and the Visa Office Recharge Form.
Letter of Request for PR Sponsorship	Letter Template from the Department Chair justifying the need to fill the position and how the Foreign National will benefit UCLA.	Department Coordinator signed by the Department Chair This letter must be submitted together with the PR Department Sponsorship Request Form.

2111	DESCRIPTION	WHO MUST COMPLETE
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2111 and 2113 Initial Application Request	This form is used to request 2111 or 2113 Special Programs License for Foreign M.D.	Department Coordinators The department coordinators must initiate a 2111/2113 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the MBC Forms and other required documents plus Visa Office Recharge Form.
2111 and 2113 Renewal Application Request	This form is used to request the renewal of 2111 or 2113 Special Programs License for a Foreign M.D.	Department Coordinators This letter must be submitted together with the 2111/2113 Renewal Application.
2111 Department Letter to Request Dean’s Office Support	Letter Template from the Department Chair requesting the DGSOM Dean’s Office support of the Appointment pursuant to Section 2111.	Department Coordinator signed by the Department Chair This letter must be submitted directly to Joan Cerera together with the following: Initial/Extension Application Request MBC 2111/2113 Application Required Documents Recharge Fee (P39) for the Vice Dean of Faculty approval and signature

2113	DESCRIPTION	WHO MUST COMPLETE
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2111 and 2113 Initial Application Request	This form is used to request 2111 or 2113 Special Programs License for Foreign M.D.	Department Coordinators The department coordinators must initiate a 2111/2113 Action in VITS for records and reports keeping and must send this form to Joan Cerera together with the MBC Forms and other required documents plus Visa Office Recharge Form.
2111 and 2113 Renewal Application Request	This form is used to request the renewal of 2111 or 2113 Special Programs License for a Foreign M.D.	Department Coordinator signed by the Department Chair This letter must be submitted together with the 2111/2113 Renewal Application.
2113 Department Letter to Request Dean’s Office Support	Letter Template from the Department Chair requesting the DGSOM Dean’s Office support of the Appointment pursuant to Section 2113.	Department Coordinator signed by the Department Chair This letter must be submitted directly to Joan Cerera together with the following: Initial/Extension Application Request MBC 2111/2113 Application Required Documents Recharge Fee (P39) for the Vice Dean of Faculty approval and signature

MBC Letters	DESCRIPTION
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Physicians and Surgeons Certification for 2113 Service	Letter Template indicating the completion 36 months clinical services, pursuant to Section 2113.
2060 Exemption Request Letter