Phase Supervisor - I certify that:
1. I have reviewed, understand, and will follow this Training/Internship Placement Plan (T/IPP);
2. I will contact the Sponsor at the earliest possible opportunity if I believe that the Trainee or Intern is not receiving the type of training delineated on
3. I will actively support the Sponsor by adhering to all applicable regulatory provisions that govern this program (see 22 CFR Part 62);
4. The Trainee or Intern named in this T/IPP will not displace full-or part-time, seasonal or permanent American workers, or serve to fill a labor need;
5. I will conduct the required periodic evaluations of the Trainee or Intern named in this T/IPP;
6. I will notify the designated Sponsor contact at the earliest available opportunity regarding any concerns about, changes in, or deviations from this
7. I will notify the Sponsor in the event of an emergency involving the Trainee or Intern named in this T/IPP, as well as any information that I receive
about the Trainee or Intern that might have an effect on that exchange visitor's health, safety, or welfare;
8. I will notify the Sponsor if I receive information regarding a serious problem or controversy involving the Trainee or Intern named in this T/IPP that
could be expected to bring the Department of State, the Exchange Visitor Program, or the Sponsor's exchange visitor program into notoriety or
9. I am participating in this Exchange Visitor Program in order to provide the Trainee or Intern named in this T/IPP with training or an internship as
delineated in this T/IPP;
AUTHORITIES: The information is sought pursuant to Section 102 of the Mutual Educational and Cultural Exchange Act of 1961, as amended (the
Fulbright-Hays Act)(22 U.S.C. 2452) which provides for the administration of the Exchange Visitor Program (J visa).
PURPOSE: The information solicited on this form will be used to provide clarity of training and intern programs offered by entities designated by the
U.S. Department of State to conduct exchange visitor programs; for general statistical use; and to administer the Trainee and Intern categories of the
Exchange Visitor Program.
ROUTINE USES: The information on this form may be shared with entities administering the program on behalf of the Department; federal, state,
local, or foreign government entities for law enforcement purposes; to members of Congress in response to a request on your behalf . More
information on the Routine Uses for the system can be found in the System of Records Notice State-08, Educational and Cultural Exchange Program
DISCLOSURE: Participation in this program is voluntary; however, failure to provide the information may delay or prevent participation in the
Exchange Visitor Program.
PRIVACY ACT STATEMENT
PAPER WORK REDUCTION ACT
Public reporting burden for this collection of information is estimated to average 2 hours per response, including time required for searching existing
data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: ECA/EC, SA-4, U.S. Department of State, Washington, DC 20522.
Page 5 of 5
Printed Name of Supervisor
Signature of Supervisor
10. I certify that this training or internship meets all the requirements of the Fair Labor Standards Act, as amended (29 U.S.C. 201 et seq.) I also
certify that training or internships in the field of agriculture meet all requirements of the Migrant and Seasonal Worker Protection Act, as amended
(29 U.S.C. 1801 et seq.).
11. I declare and affirm under penalty of perjury that the statements and information made herein are true and correct to the best of my knowledge,
information and belief. The law provides severe penalties for knowingly and willfully falsifying or concealing a material fact, or using any false
document in the submission of this form.
click to sign
click to edit