Oklahoma J-1 Visa Waiver Applications 2022-2023

Oklahoma J-1 Visa Waiver Applications 2022-2023

Department of State Case #*

Please fill out the First Name, Last Name, and Title of the person submitting the request to OSDH for the J-1 Waiver (EX: Bob Jones, JD)*

What is your email address, to which you can be reliably reached?*

Attention

When entering the HPSA IDs, use https://data.hrsa.gov/tools/shortage-area/by-address to enter the facility's address. HPSAs in Proposed for Withdrawal Status are considered if there is not a Designated HPSA.

Enter the HPSA ID of the Designated, Primary Care HPSA. If there is not one, enter the HPSA ID of the Proposed for Withdrawal Primary Care HPSA.

Do one of the facility sites have a HPSA ID? (Reference: https://data.hrsa.gov/tools/shortage-area/hpsa-find)*

Select or enter value

Physician's Date of Birth*

Physician Full Name (As appears on DOS Form 3035)*

What is the Physician's preferred title and name? (EX: Dr. Jones)*

Physician Specialty*

What is the Physician's Last Country of Residence?*

What is the Physician's Country of Birth?*

Starting with the facility that the Physician dedicates and/or will dedicate most of their time to, what is the Facility or Employer Name?*

First Facility Address 1*

First Facility Address 2

First Facility City*

First Facility State*

First Facility Zip Code*

First Facility County*

First Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)*

Do you have an additional Practice Address to enter information for?*

Select

Facility or Employer Name

Address 1

Address 2

City

State

Zip Code

County (Second Facility)

Second Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Do you have an additional Practice Address to enter information for?*

Select or enter value

Facility or Employer Name

Address 1

Address 2

City

State

Zip Code

County (Third Facility)

Third Facility HPSA ID (https://data.hrsa.gov/tools/shortage-area/by-address)

Please upload the application package*

For reference, the application package is located at https://oklahoma.gov/content/dam/ok/en/health/health2/aem-documents/organization/center-for-health-innovation-and-effectiveness/J12021-22%20pkg.pdf

Drag and drop files here or

Is this application complete and ready to submit?*

Yes

Send me a copy of my responses

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