Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
J-1 CHANGE FORM
The J-1 Exchange Visitor must also report the change of Personal Information (i.e.: address, email and/or phone number) to RCUH Human Resources via the RCUH Employee Self-Service (ESS) System.
J-1 Exchange Visitor Name:
New Updated Information
1. Personal Information.
Check the box(es) below in which the change will apply to: J-1 Exchange Visitor
J-2 Dependent(s)
 Failure of the J-1 Exchange Visitor/J-2 to report
personal information & address changes may result in termination of J-1 program and employment.
J-1 Exchange Visitor: Email Address:
Phone Number:
J-2 Exchange Visitor(s): Name:
Email Address: Phone Number:
2. Home Address for J-1/J-2 Exchange Visitor(s)
New Home Address:
New Mailing Address:
3. Mailing Address for J-1/J-2 Exchange Visitor(s) – if different from home address
4. Worksite Address for J-1 Exchange Visitor. Please select one of the following options:
Additional work location (multiple work sites) Change to my work location on my DS-2019 (new)
New/Additional Worksite Address:
5. FTE and work schedule for J-1 Exchange Visitor
New FTE and work schedules:
6. Shorten/Termination of J-1 Program:
Shorten of J-1 Program must be reported to RCUH Human Resources within ten (10) days. This form is required in addition to the standard RCUH Termination of Employment procedure.
Termination of J-1 Program due to an exchange visitor’s violation of the Exchange Visitor Program regulations must be reported to RCUH Human Resources immediately. The Exchange Visitor and the dependents should prepare to leave the United Stated immediately.
Indicate Reason for Shorten/Termination of Program/Employment:
Indicate Last Day of Program/Employment: / / (mm/dd/yyyy)
______________________________________ ______________________ Signature of J-1 Exchange Visitor Date
______________________________________ _______________________ Signature of Principal Investigator or Designee Date
RCUH Form I-106
Created 10/2005 (Revised 11/2010, 11/2013, 12/2014, 06/2016) Page 1 of 1
For RCUH Human Resources use only:
Entered by: ____________________________ Date: ________________ Checked by: ___________________________ Date: ________________