Application waiver Supplemental A Research

DEPARTMENT OF HEALTH AND HUMAN SERVICES O.M.B. NO. 0990-0001

WASHINGTON, D.C.

APPLICATION FOR WAIVER OF THE TWO-YEAR FOREIGN

RESIDENCE REQUIREMENT OF THE EXCHANGE VISITOR PROGRAM

Supplement A – Research Supplement B – Clinical Care

SECTION 1. APPLYING INSTITUTION AND PROGRAM

1 . NAME OF INSTITUTION 2. TELEPHONE, AREA & NUMBER

3. COMPLETE ADDRESS

4. NAME AND POST OF RESPONSIBLE ADMINISTRATIVE OFFICER WHO CERTIFIES THIS APPLICATION AND THE DATA IT CONTAINS

5. PROGRAM (Department or Division) IN WHICH EXCHANGE VISITOR IS ENGAGED

6. PRINCIPAL PROGRAM OFFICER, RANK AND POSITION (Supplement A) MEDICAL DIRECTOR (Supplement B)

7. SOURCE OF PROGRAM FUNDS (Supplement A ONLY) - If supported by HHS or other public funds, identify grants by source, title, number and amount and terminal dates.

SECTION 2. RELATION OF EXCHANGE VISITOR TO INSTITUTION AND PROGRAM

8. PRESENT POSITION CLASSIFICATION AND SALARY

(1) HOW LONG HAS THIS PERSON BEEN EMPLOYED IN THE INSTITUTION? (Supplement A ONLY) (2) IN THE PROGRAM?

(3) WHAT EFFORTS HAVE BEEN MADE TO REPLACE THIS INDIVIDUAL? (4) AT WHAT SALARY? (5) WITH WHAT RESULTS?

SECTION 3. EXCHANGE VISITOR FOR WHOM WAIVER IS REQUESTED

9. NAME (Surname) (Given names) (Maiden name, if married female)

10. RESIDENTIAL ADDRESS (No., Street, City, State or Province, Country)

11. CURRENT ADDRESS OF SPOUSE, IF DIFFERENT

12. OCCUPATION TITLE

13. DATE OF BIRTH (Month, Day, Year) 14. BIRTHPLACE (City, State, Country)

15. SEX: 16. MARITAL STATUS:

MALE FEMALE MARRIED SINGLE

1 7. CITIZENSHIP 18. COUNTRY OF LAST RESIDENCE BEFORE 19. IF NO LONGER IN U.S.A., STATE LAST PLACE

ENTERING U.S.A. OF U.S. RESIDENCE (City & State)

20. ALIEN REGISTRATION NO.

2 1. LOCAL IMMIGRATION OFFICE 22. DATE OF ENTRY INTO U.S.A. AS 23. EXPIRATION DATE OF CURRENT PERMIT (I-94)

WHERE REGISTERED EXCHANGE VISITOR

24. WHAT FUNDS WERE USED TO FINANCE THE EXCHANGE VISIT?

U.S. GOV’T U.N. OR AFFILIATE PRIVATE AGENCY VISITORS GOV’T OTHER

(If government agency, please identify)

FORM HHS 426

(REV. 03/03)

2 6. OTHER APPLICATIONS, IF ANY, FOR FOREIGN RESIDENCE WAIVER FOR THIS VISITOR

DATE OF APPLICATION TO FEDERAL AGENCY BY INSTITUTION

27. FAMILY (If married, list dependents)

NAME BIRTHDATE BIRTHPLACE VISA TYPE

(Spouse)

(Children)

28. EDUCATION (college, postgraduate, other)

DATES ATTENDED

NAME AND LOCATION OF INSTITUTION EXCHANGE

YEARS DEGREE (S) VISITOR

FROM TO COMPLETED RECEIVED PROGRAM #

(if any)

2 9. EXPERIENCE

PERIOD OF SERVICE

EXCHANGE

NAME AND LOCATION OF ORGANIZATION NATURE OF ASSIGNMENT VISITOR

FROM TO (Start with current assignment and work back) PROGRAM #

(if any)

SECTION 4. CERTIFICATION OF ACCURACY OF INFORMATION AND APPLICATION

Signature of Principal Program Officer (Supplement A) DATE

Signature of Medical Director (Supplement B) DATE

Signature of Responsible Administrative Officer DATE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0900-0001. The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: DHHS/OS/OIRM/PRA, 200 Independence Avenue, S.W., Washington, D.C. 20201, Room 531-H-95, Attn: PRA Reports Clearance Officer.