Department Notification of Scholar's Departure

This form is to be used by all UW-Madison departments that admit J-1 scholars. Please fill out the sections below within 10 days of a scholar's termination of their program within that department.

Department Information

Department's Name:
Department's Phone #
Name of person completing form:
E-mail of person completing form:

Scholar Information

Last Name:
First Name:
Middle Name:
Today's Date:(mm/dd/yy)
Departure Date From UW-Madison:(mm/dd/yy)