Division of
INTERNATIONAL
SERVICES
Request for Visiting Program Participant:
Part I
INSTRUCTIONS
— To be completed by the Institute/Center —
In order for the Division of International Services (DIS), Office of Research Services (ORS), to process your Institute or Center’s (IC) request
for a selected foreign national scientist to participate in the NIH Visiting Program (VP), please complete this form. In addition, if this request
is for a scientist new to the NIH or a returning scientist (i.e. one who previously terminated or ended his/her NIH stay), please have
her/him complete “Part II” of this form. Instruct her/him to return Part II of the form to you, along with the required supporting documents.
Upon completion of all applicable parts, please send this form, along with all required supporting documents, to the DIS.
Read these instructions carefully to properly complete the form. Type or print clearly. All questions MUST be answered. If not applicable,
write “N/A.” If you need more space to complete an answer, attach a continuation sheet. If a continuation sheet is necessary, write the
scientist’s name and date of birth at the top of each sheet and indicate the section to which the answer refers.
GENERAL INSTRUCTIONS
A. Type of Request
Check the appropriate type of request, based on the NIH
Designation selected in section B.
B. Designation
Check the appropriate NIH Designation for your foreign national
scientist. Note: If this request is for a Guest Researcher or Special
Volunteer designation, you must complete and submit the NIH
Form 590. Include Part II of this form (829-1) when possible.
C. Foreign National Scientist Candidate
Enter the name as it appears on the passport. Do not use initials,
even for middle names. The entire name must be spelled out. For
the date of birth, check dating formats and enter in the month/day/
year format.
D. Proposed Dates
Enter the dates of your foreign national scientist’s stay at the
NIH. If this visit is NOT for a consecutive time period, attach a
continuation sheet describing the dates of the intermittent visits—
even if the dates are tentative. If these details are not disclosed, the
DIS may use an immigration category that could bar the foreign
national from timely returning to the U.S.!
H. Funding Information
Enter the funding that will be used to support your foreign national
scientist during her/his stay at the IC. If the IC is funding the visit
(e.g. giving a stipend or salary), the IC must ensure that it is paying
within the established NIH stipend/salary/per diem/etc. levels.
Enclose evidence of outside funding as applicable (refer to the DIS
checklists under “What to Send”).
I. Research Program
Describe the research program that your foreign national scientist
will undertake at the IC. Provide the general research area (e.g.
genetics, biochemistry) and a full description of the research
program and experience to be obtained (using laymen’s terms as
much as possible). In addition, if the scientist is appointed to a
Full-Time Equivalent or FTE designation (e.g. Research Fellow),
please complete the “FTE Supplement” on page four.
J. Patient Contact (for M.D.’s only)
The level of patient contact must be specified in advance, and
should not change during the award/appointment/assignment dates.
If patient contact is anticipated, request it at this time.
E. Institute or Center (IC) Information
Enter the details about the sponsoring IC.
Check the appropriate level of patient contact, complete the
information, and attach the required documents. Be sure to review
the DIS Technical Advisory 4 and 4a for a summary of patient
contact by foreign national scientists, including instructions for the
“Four-Point Memorandum” required for incidental patient contact:
http://dis.ors.od.nih.gov/advisories/techadvisories.html
F. Work Site Information
Enter the location where your foreign national scientist will be
placed. List the primary site and additional work site, if any. If
there is more than one additional work site anticipated (even if
temporary), please attach a continuation sheet.
NIH-sponsored J-1 Exchange Visitors are limited to incidental
patient contact. Additionally, non-FTE designations are generally
prohibited from having full patient contact (exceptions on a caseby-case basis). Guest Researchers are not permitted any level of
patient contact.
G. Work Schedule
Check the appropriate work schedule.
a. No patient contact: Self-explanatory.
NIH 829-1 (Rev. 8/10)
b. Incidental patient contact: Enter the information requested.
Provide a copy of the foreign national scientist’s ECFMG
Instructions, Part I, Page 1 of 2
Remove this page before sending form.
(Educational Commission for Foreign Medical Graduates)
certificate and the original “Four-Point Memorandum”
(prepared as per DIS Technical Advisory 4a). Note that a
Four-Point Memorandum is not required for renewal purposes
if there is no change in the program or sponsor/supervisor.
If this is the case, check the appropriate box.
c. Full patient contact: Enter the information requested. If your
foreign national scientist is in an NIH clinical training program,
enter the name and ID number (obtain from http://www.cc.nih.
gov/training/gme/programs.html); ACGME-accreditation
(Accreditation Council for Graduate Medical Education);
and PGY (post graduate year) level.
Provide a copy of your foreign national scientist’s ECFMG
certificate; a copy of medical licensure in the U.S. and/or country
abroad; and evidence of USMLE (U.S. Medical Licensing
Examination) or equivalent examinations, i.e. Parts I and II of
FLEX (Federation Licensing Examination) or Parts I, II, and III
of NBME (National Board of Medical Examiners).
K. Certification
Type/print the name of the signer with signature and date. Only
provide those approval signatures that are required by your IC’s
delegation of authority.
Approval by the Office of Intramural Research (OIR), Office of
Director (OD), is required for all exceptions to program provisions.
If an exception is necessary, describe the need for the exception
and send this request and justification to the OIR/OD before
submission to the DIS.
WHAT TO SEND
Submit this completed form (Part I), signed by all appropriate IC
officials, as well as “Part II” of the form, completed and signed by
the foreign national scientist.
In addition, also submit the required supporting documentation
according to the NIH designation selected in section B. Supporting
documentation requirements can be found from the DIS checklists:
http://dis.ors.od.nih.gov/forms/01_forms.html#checklist
WHERE TO SEND
Send all documentation to the DIS at the following address.
We suggest using hand-carry to ensure delivery. The DIS is not
responsible for lost packages. Lost or misdelivered packages are
not grounds for the DIS to expedite processing!!
Before submission, please make a copy of all documentation for
the IC’s records.
PROCESSING INFORMATION
Once all required forms are received, the request will be logged
into our database and checked for completeness in accordance
with immigration rules and regulations, as well as NIH policies
and procedures.
Please refer to the DIS Processing Times advisory which describes
how long it will take the DIS to process the case, as well as other
agencies that may be involved in the process. It also provides tips
on how to establish a proposed begin date:
http://dis.ors.od.nih.gov/advisories/techadvis_no01.html
STATUS INQUIRIES
The DIS “IC View” allows designated IC Administrative “Key
Contacts” to access the DIS online case status check system,
known as the “IC View.” The Key Contact is knowledgeable about
the IC’s requests and internal approval process, and has access to
the DIS IC View. Status inquiries should begin with checking the
IC View.
Refer to the DIS Processing Times advisory for more information
on case processing:
http://dis.ors.od.nih.gov/advisories/techadvis_no01.html
REFERENCE
For the NIH Intramural Visiting Fellow Program (VFP) Manual
Chapter, please refer to:
http://www1.od.nih.gov/oma/manualchapters/person/2300-320-3/
For the NIH Guest Researcher/Special Volunteer Programs Manual
Chapter, please refer to:
http://www1.od.nih.gov/oma/manualchapters/person/2300-308-1/
For information on Full-time Equivalent (FTE) appointments
(based on Title 42), please refer to:
http://hr.od.nih.gov/hrguidance/employment/title42.htm#Pay
For the DIS Technical Advisories, please refer to:
http://dis.ors.od.nih.gov/advisories/techadvisories.html
Division of International Services
Office of Research Services, NIH
31 Center Drive, MSC 2028
Building 31, Room B2B07
Bethesda, MD 20892-2028
Tel: (301) 496-6166
Fax: (301) 496-0847
http://dis.ors.od.nih.gov/
NIH 829-1 (Rev. 8/10)
Instructions, Part I, Page 2 of 2
Remove this page before sending form.
Request for Visiting Program
Participant – Part I
Division of
INTERNATIONAL SERVICES
NIH Office of Research Services (ORS)
To be comPleTed by The RequesTIng InsTITuTe oR cenTeR (Ic)
A. Type of Request
Check one of the following types of request, based on the NIH Designation selected in item B.
New
Renewal/Extension
Transfer within IC
Transfer to new IC
b. designation
Select Designation
____________________________________________________
Other Designation: ___________________________________________________________
c. Foreign national scientist candidate
Last or Family Name:
First or Given Name:
Full Middle Name:
Gender:
Male
Female
Date of Birth:
(mm/dd/yyyy)
d. Proposed dates
Proposed Begin Date (mm/dd/yyyy): ___________________________________ Proposed End Date (mm/dd/yyyy): ____________________________________
e. Institute or center (Ic) Information
a. Name of Institute/Center (IC):
Select an Institute/Center
Name of Lab/Branch (spell out name):
IC Common Account Number (CAN):
b. Name of Lab/Branch Sponsor/Supervisor:
Sponsor Email Address:
Sponsor Position Title:
Sponsor Phone Number:
c. Name of IC Key Contact:
Key Contact Email Address:
Key Contact Position Title:
Key Contact Phone Number:
d. Name of OHR Contact (if scientist is appointed to FTE):
OHR Contact Position Title:
OHR Contact Email Address:
OHR Contact Phone Number:
Sponsor Building/Room:
Sponsor Fax Number:
Key Contact Building/Room:
Key Contact Fax Number:
OHR Contact Building/Room:
OHR Contact Fax Number:
F. Work site Information
Primary Site
Building/Room:
Physical Street Address (include street, city, region/province/state, country, and postal code):
Phone Number:
Fax Number:
Additional Site (if applicable)
Building/Room:
Physical Street Address (include street, city, region/province/state, country, and postal code):
Phone Number:
Fax Number:
g. Work schedule
Full-time:
Part-time – If Part-time:
Number of Hours per week:
Number of Days per week:
NIH 829-1 (Rev. 8/10) PART I, PAGE 1
_________________
__________________
FOR ORS/DIS USE ONLY
Scientist’s Name:
,
h. Funding Information
Will the foreign national scientist receive funding from the NIH?
Yes No – If Yes, provide the following: a. Amount of funding (per year in USD): $ ____________________________________________________________
b. NIH funding type: Stipend Salary Per Diem Honorarium Other: _____________________________
c. FPS Number (for Visiting Fellows only): ____________________________________________________________
Will the foreign national scientist receive funding from outside the NIH?
Yes No – If Yes, provide the following: a. Amount of funding (per year in USD): $ ____________________________________________________________
b. Source of funding (list name of funding organization): _________________________________________________
c. Type of funding (e.g. grant, employer salary): ________________________________________________________
d. Duration of funding (list begin and end dates): _________________________ to ___________________________
e. Type of Institution Providing Funding: Government Academic Organization Private Sector
Other ______________________________________________________
Will the foreign national scientist receive additional funding?
No
Yes – If yes, describe type of funding (e.g. on-call coverage supplement, relocation expenses), source and dates the funding is available:
I. Research Program
General area of research (e.g., genetics, biochemistry): ____________________________________________________________________________________
Description of research program/duties:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
J. Patient contact (for m.d.’s only)
a. No patient contact
b. Incidental patient contact Furnish: • Four-point Memorandum
Four-point memorandum not needed, no change in program (for renewals only)
• ECFMG Certificate No. ______________________________ dated ____________________________ (attach copy)
c. Full patient contact
Furnish: • ECFMG Certificate No. ______________________________ dated_______________________________________
• Current medical licensure:
U.S. (specify state) Select State
_________________________________ and/or country ________________________________
Select Country
Valid from _______________________ to ___________________________
• USMLE Exam: No Yes (Provide copy)
(or equivalent – see instructions)
Passed Step 1? Step 2 CK? Step 2 CS? Step 3?
• Name of NIH Clinical Training Program and ID # _____________________________________________________
• Is this program ACGME accredited? Yes No
• PGY Level: ______________________________
NIH 829-1 (Rev. 8/10) PART I, PAGE 2
Scientist’s Name:
,
K. Certification
The IC has evaluated the academic and professional credentials of the prospective foreign national scientist, and considers him/her to be qualified to participate in
the proposed research program under all applicable NIH policies and procedures. In addition, we have determined that the scientist has sufficient English proficiency
to successfully carry out the proposed research program. If sponsored as a J-1 Exchange Visitor, we understand that the scientist cannot accrue tenure.
We certify that the information on this request is true and correct and understand the foreign national scientist may be terminated if:
• Fails to participate in the proposed research program;
• Engages in unauthorized employment; and/or
• If sponsored as a J-1 Exchange Visitor, fails to maintain required health insurance for him/herself and J-2 dependent(s).
We understand that information and materials submitted with this request may be shared with other government agencies. We also understand that final
authorization to sponsor/employ the foreign national rests with the Department of State (DOS) and Department of Homeland Security (DHS) under all applicable
immigration regulations. The award/appointment/assignment is not official until cleared by the Division of International Services/ORS.
I. sPonsoR sIgnATuRe
Lab/Branch Sponsor signature (Type name, title, signature):
Date:
II. Ic APPRoVAl sIgnATuRes
Lab/Branch Chief (Type name, signature):
Date:
IC Scientific Director (Type name, signature):
Date:
IC Director (Type name, signature):
Date:
IC Administrative Officer (Type name, signature):
Date:
III. excePTIon To PRogRAm PRoVIsIons
Approval by the Office of Intramural Research (OIR), Office of Director (OD), is required for all exceptions to program provisions. If an exception is necessary,
please indicate below.
Brief description for reason for exception:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
OIR/OD Approval (signature):
Date:
submIT ThIs comPleTed FoRm, As Well As “PART II” oF The FoRm (completed by the foreign national scientist) And All RequIRed
suPPoRTIng documenTs VIA HANd-cArry To The dIs. beFoRe submIssIon, mAKe A coPy FoR The Ic RecoRds. ThAnK you FoR
youR AssIsTAnce And cooPeRATIon!
Division of International Services
Office of Research Services
National Institutes of Health
31 Center Drive, MSC 2028
Building 31, Room B2B07
Bethesda, MD 20892-2028
Tel: (301) 496-6166
Fax: (301) 496-0847
NIH 829-1 (Rev. 8/10) PART I, PAGE 3
Scientist’s Name:
,
FTe suPPlemenT
Complete this supplement if the foreign national scientist is being appointed to a Full-Time Equivalent or FTE designation (e.g. Research Fellow (VP)
position). The purpose of this form is to capture details about the FTE position that are necessary to request a Prevailing Wage (PW) determination.
Type or print clearly. All questions MUST be answered. If you need more space to complete an answer, attach a continuation sheet. If a continuation sheet
is necessary, write the scientist’s name and date of birth at the top of each sheet and indicate the section to which the answer refers. Again, complete this
supplement only if the designation requested is an FTe. Do not complete this for non-FTE designations (e.g. Visiting Fellows).
A. What is the major/field of study required for the position? _________________________________________________________________________________
B. What is the minimum degree required for the position (e.g. M.D., Ph.D.)? ____________________________________________________________________
C. What is the estimated hourly work schedule (e.g. 8:00 am to 5:00 pm)? _____________________________________________________________________
D. Will the position supervise the work of other employees?* No Yes;
If yes, list the number of those to be supervised: ________________________________________________________________________________________
*Answer yes only if the FTE will be in charge of completing an employee’s performance plan (e.g. acting as the Rating Official on a Performance Management
Appraisal Program or PMAP). Do not include any mentoring activities.
E. Will travel be required to perform the job duties? No Yes;
If yes, describe the travel requirements: ______________________________________________________________________________________________
F. Does the position require training? No Yes;
If yes, specify the number of months of training required and the name of the field(s) where training is required:
Months ________________ Field(s) _________________________________________________________________________________________________
G. Does the position require employment experience? No Yes;
If yes, specify the number of months of experience required and indicate which occupation the employment experience is required:
Months ________________ Occupation ______________________________________________________________________________________________
H. Are there any special requirements for the position, such as any specific skill(s), licenses, certificates/certifications, etc.? No Yes;
If yes, describe the special requirements: _____________________________________________________________________________________________
NIH 829-1 (Rev. 8/10) PART I, PAGE 4
