Scholar's Supervisor Completion Notification Form

Scholar's Supervisor Completion Notification Form
As required by the U.S. Department of State, program sponsors of Exchange Visitor Programs must report when a J-1 scholar is ending his/her program participation. The following information should be completed, reviewed with the Exchange Visitor, and confirmed, before submitting to ISS (International Students and Scholars). Notification of intent to end participation is required BEFORE the ending date on the Form DS-2019.
Name of J-1 Visitor Name of J-1 Visitor First Last
Program End Date Program End Date / MM / DD YYYY
Please check all that apply:

Please check all that apply: Scholar has successfully met the program objectives Scholar has NOT met the program objectives Scholar is leaving the program earlier than anticipated Scholar has already terminated participation in the program Scholar maximized his/her stay as a J-1 scholar Alternative nonimmigrant options to continue program participation were discussed with this scholar (i.e. Change of Status to H-1B or other visa)
Comments:
Name of Person Completing This Form Name of Person Completing This Form First Last
Title
Email
Department
Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
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