The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

pPBgwzn8xkXLM89StPmiYdnhN4yj

Request to Petition for a Waiver Questionnaire

Returning?

A A A

Please answer all items in this questionnaire. The information provided is required and will assist with the HHS/Conrad 30 J-1 Waiver application with the State of Kansas Department of Health and Environment (KDHE).

HHS/Conrad 30 J-1 Waiver applications and initial H-1B petitions are filed by Bordeau Immigration Law. The information provided in this questionnaire will be forwarded to Bordeau Immigration Law.

Last Name:

* must provide value

First Name:

* must provide value

Gender:

* must provide value

Other:

Country of Citizenship:

Current J-1 Status End Date:

Desired Employment Start Date:

Please upload a copy of the candidate's CV/resume.

* must provide value

Upload file

Sponsoring Department Name:

* must provide value

Administrator's Name:

* must provide value

Administrator's Phone Number:

Administrator's Email Address:

Supervisor's Name:

* must provide value

Supervisor's Phone Number:

Supervisor's Email Address:

Position Title:

Was this position approved by PMPC?

* must provide value

Yes No

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Please note that PMPC approval is required in order to be able to request to petition for a waiver candidate.

Offered Total Salary:

UKP Salary Amount:

KUMC Salary Amount:

Will work be performed at multiple sites?

* must provide value

Yes No

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Please list addresses for all locations where employee will work:

* must provide value

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Position Type:

* must provide value

Primary Care Specialist (i.e. Family Medicine, Internal Medicine, Pediatrics, Obstetrics and Gynecology, Emergency Medicine, Psychiatry)

Non-Primary Care Specialist

Type of Primary Care Specialist:

* must provide value

Type of Non-Primary Care Specialist:

* must provide value

Will the physician provide training to medical students, residents, and/or fellows?

* must provide value

Yes No

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If yes, please provide more details.

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Will the specialty position support the ability to identify and manage time critical diagnoses?

* must provide value

Yes No

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If yes, please provide more details.

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Will the specialty position support the care for patients with chronic diseases?

* must provide value

Yes No

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If yes, please provide more details.

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Please provide an estimate percentage of the amount of time the physician will spend.

Providing inpatient care:

* must provide value

Providing outpatient care

* must provide value

Please provide the following data related to department's need for the physician's services.

Current specialist to patient ratio:

* must provide value

Desired specialist to patient ratio:

* must provide value

Were there any staffing changes justifying the need of the physician?

* must provide value

Yes No

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If yes, please provide more information:

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What are the consequences to the department and the treatment of low income patients if the Conrad 30 is not approved and the physician is unable to start the position?

* must provide value

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Please provide any additional information about the unmet need of physicians in your area and about the underserved population.

* must provide value

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Date the position was advertised:

* must provide value

Was the position advertised in a local or regional publication or platform?

* must provide value

Yes No

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Please upload copies of the advertisements.

Upload file

Was the position advertised in a national publication or platform?

* must provide value

Yes No

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Please upload copies of the advertisements.

Upload file

How many applicants applied for this position?

* must provide value

How many applicants were interviewed?

* must provide value

Were any U.S. workers offered the position and declined?

* must provide value

Yes No

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If yes, please provide more details.

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Were any U.S. workers interviewed, but not offered the position?

* must provide value

Yes No

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If yes, please provide the reason the offer was not extended to the U.S. workers:

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Please provide any additional information about the recruitment process for this position.

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KUMC privacy practices on how personal information is collected, stored and used is available at the links below:

Click here for the "GDPR Privacy Notice".
Click here for the "KUMC Privacy Statement".

ACKNOWLEDGEMENT:

The information provided in this form is true and correct to the best of my knowledge. I have read and understood KUMC privacy practices.

Department Administrator Completing this Form Name:

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.