J-1 Waiver Questionnaire

SECTION 01 · CLIENT INTAKE

Contact information

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Your first name *

Your last name *

Your email address *

Best contact phone

Your role

Preferred contact method and any instructions

SECTION 02 · CLIENT INTAKE

Waiver basis and case status

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Which J-1 waiver basis are you considering?

Current stage

What is your present immigration status?

Are you inside or outside the US?

Have you been advised that INA 212(e) applies?

Why do you believe you are subject to INA 212(e)?

Have you requested a DOS advisory opinion on INA 212(e)?

DOS advisory opinion reference, if any

Advisory opinion conclusion, if any

Existing DOS J-1 waiver case number

Existing USCIS I-612 receipt number

Other pending applications, waiver concerns or case timing

SECTION 03 · CLIENT INTAKE

Exchange visitor identity

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

J-1 given name as shown in passport

J-1 middle name(s)

J-1 family name as shown in passport

Preferred title

Maiden or birth name

Date of birth

City of birth

State or province of birth

Country of birth

Country of citizenship or nationality

Country of last foreign residence

Country of legal permanent residence when last DS-2019 was issued

Sex as shown on most recent DOS/USCIS records

Current marital status

Alien registration number (A-Number), if any

USCIS online account number, if any

Social Security number, if any

Current or most recent I-94 number

SEVIS number

Passport number

Passport issuing country

Passport expiration date

All other names ever used

Entry 1

Given name

Family name

Reason / dates used

SECTION 04 · CLIENT INTAKE

Addresses and communication

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Current physical address: street and number

Apartment, suite or floor

Current city

State or province

Postal code

Country

Is your mailing address the same as physical address?

Full mailing address (if different)

Last US address, if now living abroad

Last US city of residence

Last US state of residence

Exchange visitor email

Exchange visitor home or mobile phone

Exchange visitor work phone

Preferred correspondence destination

SECTION 05 · CLIENT INTAKE

J-1 exchange program and DS-2019 history

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Most recent J-1 program sponsor

Most recent exchange visitor program number

J-1 exchange visitor program category

Major field of activity

Current occupation

Subject or field code from DS-2019

Do you possess all DS-2019 or IAP-66 forms for every program?

Did any program receive US, home-government, or international organization funding?

Name of any funding agency, government, grant, scholarship or stipend

Explain sources and purposes of funding

Was your program directly or indirectly financed by a US government agency?

Was your program directly or indirectly financed by a foreign government?

Have you been identified as subject based on the Exchange Visitor Skills List?

Did you enter J-1 to participate in graduate medical education or training?

First J-1 medical training start date

List every exchange visitor program and DS-2019 (including transfers and extensions)

Entry 1

SEVIS ID

Program number

Sponsor / institution

J-1 category

Purpose / position

Program beginning date

Program ending date

Field / subject code

Funding amount and sources

DS-2019 reason or purpose

SECTION 06 · CLIENT INTAKE

US immigration, entries, and status history

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

First entry date using original J-1 visa

First J-1 port of entry

First J-1 entry state

Original J-1 visa control number

Original J-1 issuing post

Did you change to J-1 status while already in the US?

Date of change to J-1 status

Change of status receipt or approval number

Most recent J-1 entry date

Most recent J-1 port of entry

Most recent J-1 entry state

Most recent departure from the US, if abroad

Class of admission and admit-until date (or D/S)

Was any time in the US not covered by a DS-2019 / IAP-66?

Explain uncovered periods, status changes, or gaps

Other immigration petitions, green card applications or visa applications

US status violations, overstays, unauthorized work, or other concerns

Additional J-1 or J-2 visa issuances and US trips

Entry 1

Visa classification

Visa number / control

Issue date

Issuing post

Entry date

Port of entry

Departure date

SECTION 07 · CLIENT INTAKE

Prior waiver requests and advisory opinions

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Have you previously requested a J-1 waiver?

Most recent waiver case number

Basis of prior waiver request

Date of prior waiver request

Result, denial, approval, pending or withdrawal

Have you requested a prior advisory opinion?

Most recent advisory opinion case number

Have you or spouse previously filed any related USCIS benefit applications?

Relevant receipts, notices, refusals, or denials

SECTION 08 · CLIENT INTAKE

Spouse and J-2 dependents

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Spouse full legal name

Spouse date of birth

Spouse country of birth

Spouse country of citizenship

Spouse country of last foreign residence

Spouse present immigration status

Is your spouse in independent J-1 status?

Has spouse filed a separate J waiver case?

Spouse separate J waiver case number

Do you expect spouse to be included in this waiver request?

Do you have J-2 spouse or child dependents to include?

Are you a J-2 dependent seeking an exceptional separate waiver?

If J-2 only, explain death, divorce, age 21, or other humanitarian circumstance

Every J-2 dependent (including children and spouse, if relevant)

Entry 1

Given name

Family name

Date of birth

Country of birth

Country of citizenship

Country of last foreign residence

Relationship to J-1

Immigration status

Include in waiver?

SECTION 09 · CLIENT INTAKE

Document availability and case preparation

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Do you have every DS-2019 / IAP-66?

Do you have passport identity pages and every relevant J-1/J-2 visa?

Do you have US entry and I-94 records?

Do you have grant contracts, stipend, training or funding documentation?

Do you have prior DOS / USCIS cases, notices and advisory opinions?

Are English translations needed for any relevant documents?

Other records available or missing

Additional explanation for the firm

SECTION 10 · CLIENT INTAKE

No Objection Statement supporting questions

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Government expected to issue the No Objection Statement

Embassy, consulate or designated ministry handling request

Has the government issued or transmitted the statement?

Expected or actual transmittal date

Government No Objection reference number

Describe why home government has no objection and basis of waiver request

Any medical-training, funding, scholarship or program restrictions?

Additional embassy communications or outstanding requirements

SECTION 11 · CLIENT INTAKE

Interested US Federal Government Agency request

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Interested US federal agency name

Government program, project, research or activity

Agency office or government point of contact

Agency request letter status

Why is granting the waiver in the US public interest?

Why would two-year return be detrimental to the agency project or program?

Your role in the project, position and employer

Project or employment start and end dates

Funding agreement, appointment, grant, contract or offer details

Are you seeking an IGA waiver as a foreign medical physician?

Letters and evidence agency can provide

SECTION 12 · CLIENT INTAKE

Conrad State 30 physician waiver

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

US graduate medical education or training details

State public health department expected to sponsor

State agency or designee contact

Employing clinic, hospital or healthcare facility

Employer name and full address

Health Professional Shortage Area / Medically Underserved Area designation, if any

Employment contract, position, and specialty

Planned patient population, full-time service and location

Contract term and intended start date

Medical licenses and professional credentials

State sponsorship application status

Potential restrictions, federal funding, or prior issues

Recruitment, needs evidence and required state documents

SECTION 13 · CLIENT INTAKE

Exceptional hardship waiver narrative (I-612)

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

US citizen or permanent resident spouse or child who would experience hardship

How would family separation cause exceptional hardship?

How would relocation to the home country cause exceptional hardship?

Medical conditions, treatment, medications or access to specialists

Psychological, developmental or emotional hardship

Current income, savings, debts, housing, education and financial obligations

Employment, professional license or career disruption

Child schooling, special education or developmental needs

Country conditions, safety, language and cultural barriers

Caregiving responsibilities and extended-family support

Prior separations and expected two-year effects

Explain the exceptional hardship in combination

Supporting medical, financial, psychological and other evidence

SECTION 14 · CLIENT INTAKE

Qualifying spouse and child evidence (I-612)

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Qualifying spouse first name

Qualifying spouse middle name

Qualifying spouse last name

Spouse date of birth

Spouse US citizenship or permanent residence

How did spouse obtain US citizenship?

Naturalization or citizenship certificate number

Naturalization date

Naturalization place

Spouse LPR A-Number

Date spouse became a permanent resident

Place spouse became a permanent resident

Spouse permanent residence category

Household annual earnings, income and savings

Expenses, liabilities and dependent obligations

Each qualifying US citizen or LPR child or additional family member

Entry 1

Full name

Date of birth

Relationship

US citizen or LPR

Citizenship acquisition or LPR basis

Certificate / A-Number

Date citizenship or LPR acquired

Place citizenship or LPR acquired

Specific hardship

SECTION 15 · CLIENT INTAKE

Persecution claim and I-612 supporting information

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Country of feared return

Protected ground(s)

Explain why returning would subject you to persecution

Describe any past threats, attacks, detentions or persecution

Who carried out or threatens persecution?

Government involvement and availability of protection

Important incidents, chronology, places and dates

Political, religious, racial or other background relevant to claim

Threats to family members and other similarly situated persons

Country reports, news, affidavits and other supporting evidence

Would internal relocation within home country be safe? Explain.

Any asylum, refugee or protection filings or decisions

SECTION 16 · CLIENT INTAKE

I-612 supplementary information

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

I-612 names and numbers of all exchange programs not already listed

I-612 major field of activity (if different)

Occupation for I-612

Last J-1 entry date for I-612

Last J-1 port of entry city and state

Most recent US departure date (if abroad)

Spouse relationship to this waiver filing

Summary for signed I-612 hardship or persecution statement

I-612 documentary evidence available

Additional information: USCIS page, part and item

Entry 1

Form page

Part number

Item number

Additional explanation

SECTION 17 · CLIENT INTAKE

Review and submit

Only first name, last name, and email are required. All other questions are optional. Please give complete, accurate details to help our office assess and prepare your J-1 waiver request.

Anything else our office should know?

Contact information

Waiver basis and case status

Exchange visitor identity

Addresses and communication

J-1 exchange program and DS-2019 history

US immigration, entries, and status history

Prior waiver requests and advisory opinions

Spouse and J-2 dependents

Document availability and case preparation

No Objection Statement supporting questions

Interested US Federal Government Agency request

Conrad State 30 physician waiver

Exceptional hardship waiver narrative (I-612)

Qualifying spouse and child evidence (I-612)

Persecution claim and I-612 supporting information

I-612 supplementary information

Review and submit

Secure submission