Type of Non-Employee Access Required:
* must provide value
Student Intern - Must be actively enrolled in an educational program (High School, Undergraduate, Graduate, Med student, etc.) and interning for purpose of gaining experience for their education/program. **Student access is NOT applicable to Research Fellows/Post-Doctoral Associates, Trainee roles**DO NOT USE THIS REDCAP FOR RESEARCH FELLOWS/POST-DOC ASSOCIATE**
Research Visitor - Employed Researchers with external salary funding who will collaborate on a research project with a MGH CGM Faculty Member. **Visitor access is NOT applicable to Research Fellows/Post-Doctoral Associates, Trainee roles**DO NOT USE THIS REDCAP FOR RESEARCH FELLOWS/POST-DOC ASSOCIATE**
Observer - Observers will visit 3+ weeks and are expected to be accompanied at all times. As such, the badge they would receive doesn't grant door access. Observers are expected to not be working/performing any tasks at MGH and as such they don't get MGB email access or other MGB network access etc. as they are only here for observation.
For all MGH Observers who will be at CGM for 3 weeks or more, we must obtain an MGH Observership Agreement to be signed by both the PI (sponsor/host) and Observer (visitor).
Non-Employee First Name
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Non-Employee Last Name
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What is the non-employee's email address?
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Which CGM Faculty Member's lab will the Student Intern or Research Visitor directly intern or collaborate with?
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Alexandre Lussier (Dunn Lab) Christiano Alves (Kleinstiver Lab) Christopher D. Anderson Harrison Brand (Talkowski Lab) Raghu Chivukula Melina Claussnitzer Susan L. Cotman William Crowley Mark Daly Alysa Doyle Erin Dunn Florian Eichler Jose C. Florez Tian Ge Kathryn Gray Yulia Grishchuk James Gusella Stephen J. Haggarty Konrad Karczewski Rakesh Karmacharya Raymond J. Kelleher III William Taylor Kimberly Ben Kleinstiver Jong-Min Lee Phil Hyoun Lee Alexandre Lussier (Dunn Lab) Daniel MacAurthur Marcy E. MacDonald Alicia Martin Vamsi K. Mootha Ricardo Mouro Pinto Patricia Musolino Pradeep Natarajan Benjamin Neale Annie O'Donnell Christopher Newton-Cheh Aarno Palotie Roy H. Perlis Vijaya Ramesh Heidi L. Rehm Elise Robinson Jonathan Rosand Kaitlin Samocha Richa Saxena Jeremiah Scharf Ihn Sik Seong Brian Skotko Susan A. Slaugenhaupt Jordan W. Smoller Alexander Soukas David Sweetser Michael Talkowski Miriam Udler James Walker Vanessa Wheeler Wei Zhou
Name of who should be contact for correspondence in the lab (if not the PI/Faculty Member directly). Please include MGH User ID or email address.
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The student will be:
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Conducting dissertation research
Conducting elective research (not required as part of school curriculum)
Performing a research rotation
Performing a clinical rotation
Performing an administrative externship
Participating in an MGH approved program
If non-employee is a student, the student is currently enrolled in:
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High School
Undergraduate Program
Graduate Program, DDS/DMD
Graduate Program, Master's Degree
Graduate Program, MD/PhD
Graduate Program, PhD
Graduate Program, Other
Post-Bacc Program
Not currently enrolled in an educational program
I attest that the Student Intern or Research Visitor is 18 years or older:
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Yes
No
If your student intern is 16 or 17 yrs old, a Minor Intake Form will need to be filled out for Research Compliance approval. We cannot onboard through HR until compliance approval is provided.
If non-employee is a student, please note what school they attend, include department/program of study.
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If your student will work with radioactive materials, please attest to the following:
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I attest that my student will only work with radioactive materials under direct supervision
My student will not work with radioactive materials
If your student will work with biological materials, please attest to the following:
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I attest that my student is enrolled in high school and will not work with biological materials higher than BL2.
I attest that my student is enrolled in an undergraduate or graduate program and will only work with biological materials higher than BL2 under direct supervision.
I attest that my student is enrolled in a PhD program. PhD students are permitted to work with biological materials higher than BL2.
I attest that my student will not work with any biological materials.
Is this person a citizen of an OFAC-Sanctioned Country? OFAC-Sanctioned countries include: The Balkans, Belarus, Burma, Central African Republic, Cote D'Ivoire, Cuba, Democratic Republic of Congo (DRC), Iran, Iraq, Lebanon, Former Liberian Regime of Charles Taylor, Libya, North Korea, Somalia, Sudan, South Sudan, Syria, Ukraine/Russia, Yemen and Zimbabwe. Please contact Mary Gervino in the MGH Research Compliance Office if your non-employee is a citizen of one of these countries.
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Yes
No
Position Description (2-3 sentences). Please provide a DETAILED description including why this non-employee is being brought on, activities they will be working on, and what supervision will look like. Failure to do so will delay processing.
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Anticipated Start Date
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Today M-D-Y
Expected End Date
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Today M-D-Y
Have you performed a reference check?
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Yes
No
If no, please provide a reason why
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Will you be providing a stipend to your non-employee student?
* must provide value
Yes
No
Please list the fund number(s) that the stipend will be charged to.
* must provide value
Please attest that the stipend request is not using funds from an NIH Research grant. Per the HR Non-employee Office, stipends can't be used for NIH Research grants.
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Please download and complete the stipend form
Please upload the completed stipend form
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What institution will the non-employee be paid from?
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Does the non-employee require a Visa?
* must provide value
Yes
No
What type of Visa sponsorship does the Non-employee require?
* must provide value
J1 Research Scholar (Scholars with at least a completed BA that will intern for 6+ months)
J1 Short Term Scholar (Scholars with at least a completed BA that will intern for 6 months or less)
H1B
Student intern will transfer J- or H- visa from an external institution to MGH.
Citizens of the below countries require Export Control clearance from your hospital's compliance department.
* must provide value
Yes
No
If you answered 'YES' to the above question regarding Export Control Approval, please note the country of citizenship of your candidate, in the text box.
* must provide value
For student interns who require a J1 visa, a Letter of Invitation (LOI), is required for the visa request submission.
GPS uses eShipGlobal to send the initial DS-2019. Exchange Visitors pay for this service themselves.
* must provide value
Please provide a sundry fund number to cover the below noted expenses for the H1B Visa:
* must provide value
What percentage of time will the Exchange Visitor spend on RESEARCH?
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What percentage of time will the Exchange Visitor spend on OBSERVATION?
* must provide value
What percentage of time will the Exchange Visitor spend on TEACHING?
* must provide value
Will this Exchange Visitor perform responsibilities that are consistent with a Technician, Technologist, Research Coordinator, or any administrative role?
* must provide value
Yes
No
Explain the goal of the research project that the Exchange Visitor will partake in.
* must provide value
Please provide a brief summary description of the Exchange Visitor's proposed research responsibilities.
* must provide value
The U.S. Department of State requires your department to verify potential J-1 Exchange Visitors' English language proficiency by an objective measurement when screening for program eligibility (22 CFR 62.10(a)(2)). Their English must be proficient enough to communicate effectively in English while in the lab and in the broader Boston-area community.
As required by U.S. federal regulations, I confirm that this Exchange Visitor has sufficient English language ability to engage in his/her program at a Mass General Brigham institution and to function in daily life in the U.S.
* must provide value
Yes
Which objective measurements were used to verify his/her English proficiency?
* must provide value
The EV's first language is English (U.K., Australian, etc. passport)
In-person interview conducted in English
Videoconference conducted in English
Telephone interview conducted in English (only if videoconferencing is not available)
EV submitted a copy of results from a standardized English Language Proficiency Test
EV submitted signed documentation (i.e. diplomas, transcripts, proof of employment, etc.) from an English-speaking academic institution
Date of interview via in-person, video conference or telephone
* must provide value
Today M-D-Y
Name of Interviewer(s)
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I confirm that documentation of this interview is on file and can be produced if requested by the U.S. Department of State, the Partners Office for International Professionals and Students, or other organization.
* must provide value
Yes
Please include details noting Visa type, and if transferring, external institution name.
* must provide value
Will the non-employee be working remotely, onsite or hybrid?
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Remote Only
Onsite Only
Hybrid
Where will the non-employee's office/desk be located? Please note, Jim Mull will review all space assignments and will contact you if there is a problem.
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You may use this space to upload any relevant documentation
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