ࡱ> FIEe bjbjhihi 44 i i%[ #####7778oD$7oRL#999(\,w"^#((##99)R#9#99@0=R?0o"l""#To" Y : tv College and Department Deemed Export Questionnaire Instructions: On 11/23/10, the USCIS released a revised I-129 application form (used in the H1-B and O-1 petition process) that includes the requirement for an export certification for each foreign national employee. This form is intended to provide the tv Office of Export Control with information necessary to start the assessment process. It should be completed by the employees supervisor and signed by the Department Chair. The form is sent to the tv Export Control Officer. It will be returned to the submitting department and should then be sent to the International Services Office with the G-28. No university petition for H1-B or O-1 can be submitted unless this process is completed. Section A: Employee Information Employee Name: ________________________ Current Visa Type/Status: _______________________________ Country of Birth: ________________________ Country of Citizenship: __________________________________ Sponsoring Dept.: _______________________ Supervisor Name: ______________________________________ List all University accounts used to support the employees salary, and if applicable, their research: Section B: Position Information Will the employee have access to technology (software, equipment or material(s) specifically designed or developed for military (e.g. night vision, GPS Y-code, shielding, UAVs or targeting algorithms) or space (e.g. rockets, missiles, satellites, space telescopes or probes) applications? ( Yes ( No If yes, provide a list of the military or space applications below. Will the employee be provided access to tv, sponsor or third party export controlled, confidential or proprietary information, software or technical data? This would include information about the design, manufacture or repair of standard laboratory equipment that is not in the public domain; it does not include basic operation or use instructions. ( Yes ( No If yes, provide a brief description below. Will the employee be involved in any research or other scholarly activity that is not intended for public dissemination? ( Yes ( No If yes, please provide the proposal number, contract number, and sponsor below. Will the employee be provided access to any ongoing DoD, NASA or defense industry research or research results? ( Yes ( No If yes, please provide the Title of project, funding agency and brief description. Will the employee be involved in any scientific, technical, or engineering research project? ( Yes ( No If yes, please provide the following: Title of project: Funding agency: Project Identification number: A brief and lay description of the research and how results will be shared If yes or if comments have been made in any question, please forward to The Office of Export Control for review at HYPERLINK "mailto:exportcontrol@usf.edu"exportcontrol@usf.edu. If you check, all nos send the form directly to Marcia Taylor at CGS101. The person signing this is attesting that they have full knowledge of the scope of the research work of the employee: _________________________ _____________________ _____________________ Signature of tv Supervisor Print Name Date __________________________ _____________________ _____________________ Signature of tv Department Chair Print Name Date Section C - CERTIFICATION To be completed by tv Export Control Officer Export Control, administered by the Division of Sponsored Research (DSR), at the tv, has reviewed the attestations above. After review of associated agreements and the information provided by the sponsoring department, Export Control has determined that, as of the date signed:  FORMCHECKBOX  A license is required from the U.S. Department of Commerce and/or the U.S. Department of State to release such technology or technical data to the beneficiary and the petitioner will prevent access to the controlled technology or technical data by the beneficiary until and unless the petitioner has received the required license or other authorization to release it to the employee.  FORMCHECKBOX  The University has received the required license or other authorization to release information to the employee  FORMCHECKBOX  A license is not required from either U.S. Department of Commerce or the U.S. Department of State to release such technology or technical data to the employee. _____________________________ ____________________ ______________ Signature of Export Control Officer Printed Name Date Updated: 8/27/2024     tv Export Control Side  PAGE \* MERGEFORMAT 1 ANOP|}N S 3 5   0 = > ǻǯǯǯwi[PEhhDCJaJhh[CJaJh}2Xh[5>*CJaJh}2XhF 5CJ^JaJ$h}2Xh}2X5B*CJ^JaJphh}2X5B*CJ^JaJphh}2Xh}2X5CJaJhy'I5CJaJh}2Xh^Yr5CJaJh}2Xh[5CJaJh}2XhF 5CJaJ hvy5h5CJaJh{5CJaJh[5CJaJh{h{5CJaJOP 0 \ XY~yrgd,gd,gdN&d P gdN &d P gdgdgdD;$ d$d %d &d 'd -DM N O P Q a$gdF dgdvy $da$gd{ > ? 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