Form_Background Information for Visiting Scholar Request

Background Information Form for Volunteer or Visiting Scholar Agreement

The hosting ODU professor should submit this form online at least two weeks in advance of the Volunteer or Visiting Scholar Agreement's needed execution date to allow all parties to process the proposed agreement.

Some questions in this form will require the hosting ODU professor to first collect information from the proposed volunteer or visiting scholar in order for the hosting ODU professor to answer and submit this form online.

Some questions below may not be relevant due to unique circumstances, so those questions can be answered with "Not Applicable."

Do not submit this form for a Volunteer or Visiting Scholar, who will be relying on either an F-1, J-1, H-1B or other nonimmigrant visa for his or her visit. For Volunteers or or Visiting Scholars relying on such a visa, separately contact ODU's Office of Visa & Immigration Service Advising to initiate a Volunteer or Visiting Scholar Agreement for final signature by the Office of Research.

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Section I - Old Dominion University Information

Name of Old Dominion University professor who will be hosting the Volunteer or Visiting Scholar:

Hosting ODU professor's email address:

Hosting ODU professor's office postal mailing address (including office number, building name, and street):

Hosting ODU professor's phone number:

ODU Department/Center that will be hosting the Volunteer or Visiting Scholar:

Identify all additional ODU personnel (including students) who will be working on the proposed project with the Volunteer or Visiting Scholar:

Section II - Volunteer or Visiting Scholar Information

Name of Volunteer or Visiting Scholar:

Address of Volunteer or Visiting Scholar:

Email Address of Volunteer or Visiting Scholar:

Phone Number of Volunteer or Visiting Scholar:

Is the Volunteer or Visiting Scholar currently a student of a college or university?

Yes
No

If Volunteer or Visiting Scholar is currently a student at a college or university, identify his or her college/university, degree program and expected graduation date:

Is Volunteer or Visiting scholar currently employed?

Yes
No

Identify current employer of Volunteer or Visiting Scholar:

If Volunteer or Visiting Scholar is currently employed, provide name, job title, email address, and phone number of Volunteer or Visiting Scholar's supervisor.

Identify all countries in which the Volunteer or Visiting Scholar has citizenship:

Section III - Project Information

Describe the project(s) that the Volunteer or Visiting Scholar will access or work on either remotely or on campus at Old Dominion University under the proposed Volunteer or Visiting Scholar agreement:

Identify any specific risks (e.g. health hazards) particular to the project(s) that the Volunteer or Visiting Scholar may encounter:

Is there an Institutional Review Board (IRB), Institutional Biosafety Committee (IBC), or Institutional Animal Care and Use Committee (IACUC) approval for the project(s) that the Volunteer or Visiting Scholar will access or work on?

Yes
No
Not Required

Who will disclose confidential information during the Volunteer or Visiting Scholar's work either remotely or on campus at Old Dominion University (select one)?

Old Dominion University personnel only
Volunteer/Visiting Scholar only
Both Old Dominion University personnel and Volunteer/Visiting Scholar
Neither Old Dominion University personnel nor Volunteer/Visiting Scholar

Will you receive any tangible materials (not mere data) from a non-ODU entity under this collaboration with the Volunteer or Visiting Scholar?

Yes
No

Will you distribute any tangible materials (not mere data) to a non-ODU entity under this collaboration with the Volunteer or Visiting Scholar?

Yes
No

Is the project(s) that the Volunteer or Visiting Scholar will access or work on at Old Dominion University (either on campus or remotely) covered by an existing contract, subcontract, sponsored research agreement or other agreement with Old Dominion University or Old Dominion University Research Foundation?

Yes
No

Identify the contract, subcontract, sponsored research agreement or other agreement for the project(s) that the Volunteer or Visiting Scholar will access or work on at Old Dominion University (either on campus or remotely).

Will the project with the Volunteer or Visiting Scholar involve foreign travel, shipments or hand carrying of material outside the United States?

Yes
No

Will the project that the Volunteer or Visiting Scholar work on require access to classified military information?

Yes
No

Will the project that the Volunteer or Visiting Scholar will work on involve an end use or research aim related to any of the following: nuclear, foreign military, unmanned aerial vehicle, rocket, missile, chemical or biological weapons?

Yes
No

Does the proposed activity involving the Volunteer or Visiting Scholar have the potential to result in publications by ODU faculty, staff, or students?

Yes
No

Does the proposed activity involving the Volunteer or Visiting Scholar have the potential to result in inventions?

Yes
No

Can any invention(s) resulting from the research in the proposed project(s) that the volunteer or visiting scholar will work on be commercialized?

Yes
No
Not Applicable

For what duration (in number of months or years) will the requested Volunteer or Visiting Scholar Agreement need to be in effect?

Please provide any other comments, information, special circumstances, or concerns that ODU's Office of Research should be aware of prior to facilitating a Volunteer or Visiting Scholar Agreement.

Section IV - Certification

Name of preparer of this form:

Signing here acknowledges that the information provided in this form is accurate to the best of my knowledge and information gathering ability.

Sign Here

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