Western Michigan University s2

Western Michigan University

Export Control Compliance Review Worksheet

Western Michigan University (WMU) is required to demonstrate its export control due diligence and to document its adherence to United States (U.S.) export controls and trade sanctions laws.

U.S. export control laws, including the Export Administration Regulations (“EAR”), International Traffic in Arms Regulations (“ITAR”) and Office of Foreign Assets Control (“OFAC”), require that WMU obtain an export license prior to providing controlled technologies to certain foreign national employees, students, researchers, visiting scholars or collaborators. The decision whether or not to file and/or pursue an export license application is at WMU’s sole election.

Export controls, when applicable, may require WMU to receive authorization from the U.S. Government in the form of an export license. An export license permits "controlled" tangible items or software to be sent outside of the U.S., or for controlled information or software code to be shared with foreign persons in the U.S. ("deemed exports") or abroad.
An export is any oral, written, electronic or visual disclosure, shipment, transfer or transmission of commodities, technology, information, technical data, assistance or software codes to:
•anyone outside the U.S. including a U.S. citizen
•a non-U.S. individual wherever they are (deemed export)
•a foreign embassy or affiliate
Methods of Disclosure Include but are not limited to the following:

•Fax
•Telephone discussions
•E-mail communications
•Computer data disclosure

•Social Media
•Face-to-face discussions
•Training sessions
•Tours which involve visual inspections
•Access to sensitive laboratories

Export controls are frequently, but not exclusively, associated with items, information or software within the following general areas:
•Chemical, Biotechnology and Biomedical Engineering
•Materials Technology
•Remote Sensing, Imaging and Reconnaissance
•Navigation, Avionics and Flight Control
•Robotics
•Propulsion System and Unmanned Air Vehicle Subsystems
•Telecommunications/Networking
•Nuclear Technology
•Sensors and Sensor Technology
•Advanced Computer/Microelectronic Technology
•Information Security/Encryption
•Laser and Directed Energy Systems
•Rocket Systems
•Marine Technology

The following questions are to assess your country of chargeability for export control screening purposes only. This information you provide will assist the Export Control Committee in the review process and will not be used for any improper purpose.

1. Name: Department:

Email Address: Office Phone:

Street Address: Home Phone:

City: State: Country: ZIP:

2. Are you a

Yes No Citizen or National of the United States.

Yes No United States Lawful Permanent Resident.

Yes No Granted U.S. Refugee Status.

Yes No Person granted Asylum.

*** If your answer to any part of Question 2 above is “Yes,” please do not answer any of the following questions. Rather, go directly to the Signature Section at the end of this page.

If your answer to any part of Question 2 is “No”, proceed to Question 3.

3. What is your place of birth?

Yes No Have you ever acquired citizenship, nationality, or permanent resident status in a country other than your place of birth?

If “Yes”, please provide details (country(s), type of status, date of acquisition).

Comments

4. Yes No Have your ever relinquished, abandoned, or lost citizenship, nationality or

permanent residence in any country, including your country of birth?

If “Yes”, please provide details (country(s), status relinquished/abandoned/lost, and date of relinquishment / abandonment/loss):

Comments

5. Please provide your Passport Number and issuing Country in the space provided.

Please submit a copy of your passport data page(s) to include photo and expiration date.

SIGNATURE SECTION

I understand WMU reserves the right to inquire further on any matter related to the University’s export compliance obligations.

I certify that the foregoing answers are complete, true and correct to the best of my knowledge and belief.

Print Name: Date:

Signature: Date:

6. PRINCIPAL INVESTIGATOR/CHAIR/DIRECTOR/DEAN OR ASSOCIATE DEAN:

With regards to any and all research projects the individual will have access to or work on,

please answer the questions below, attaching the project’s Scope of Work (SOW) and any

additional explanation if needed for answers to questions below. Based upon your answers,

you may or may not be asked to report follow-up export control reviews on a periodic basis.

Please mark each box below with a ý following review of that section.

Category I: If the answer to any of these questions is “YES” please contact the WMU

Research Compliance Office at 1+ (269) 387-8293 immediately.

Yes No Does your proposed project(s) involve receipt or generation of classified information?

Comments

Yes No In your project(s), will you share, ship, transmit, transfer, or travel outside the U.S. with

WMU-developed, non-commercial encryption software in source code or object code form, either stand-alone or embedded in other code?

Comments

Yes No Do you know or have any reason to believe that your project(s) will support

the design, development, production, stockpiling, detection, or use of a

nuclear explosive device, chemical or biological weapon, or missile?

Comments

Yes No Does any aspect of your project(s) potentially involve commerce with, travel to, or

shipment or payment to or from Cuba, Iran, North Korea, Sudan, or Syria?

Comments

Yes No Will your project(s) utilize a global positioning system (GPS technology)

outside of the United States, either for personal travel or as project equipment?

Comments

Category II – Please answer the following key question.

Yes No Is the purpose of your project(s) fundamental research that will predictably lead to

unrestricted publication in the open research literature? (If the answer is “NO”,

please indicate whether your project(s) is instruction, service / outreach,

testing, contract training, or something else.)

See https://www.bis.doc.gov/index.php/2012-03-30-17-54-11/ecr-faqs

Comments

Category III – Please answer the following supplemental questions.

Please provide explanatory comments for any “Yes” answer, attaching additional pages if needed.

Yes No Are you aware of any provision in your existing or proposed sponsored research

agreement (contract or grant) imposing publication restrictions beyond a brief

review (up to 90 days) for patent protection and/or inadvertent release of

non-WMU confidential or proprietary information?

Comments

Yes No Will any part of your project(s) be performed at a non-US academic site

(i.e., at a site that is neither an WMU site in the United States nor another university site located within the United States)?

Comments

Yes No Will there be project participants who are not employees or students at a university campus located in the United States?

Comments

Yes No As part of your project(s), are you or WMU being asked to sign a non-disclosure

or other confidentiality agreement regarding any WMU or non-WMU item, information, data or software?

Comments

Yes No Did the funding for your project(s) originate or flow through a foreign government or foreign governmental agency? If yes, please specify.

Comments

Yes No Does your project(s) require the delivery of a prototype or research samples

to the sponsor or another non-WMU party?

Comments

Yes No Is any article to be received for, used, or developed in your project(s)

a defense article on the ITAR’s U.S. Munitions List?

[see http://www.ecfr.gov/cgi-bin/text-idx?node=pt22.1.121]

[If you need assistance, please call 1+ (269) 387-8293].

Comments

Yes No Is any information or software to be received for, used, or developed in your project(s) technical data on the ITAR’s U.S. Munitions List?

Comments

If “YES”, is that information or software already (i) published, (ii) patented, or (iii) available via the Web to all members of the public, free of charge, where WMU neither has knowledge nor exercises control over who visits the Website or downloads the information? Where?

Comments

Yes No Did you, in your project(s) proposal, explicitly discuss military applications of your

project(s)?

Comments

Yes No In your project(s), are you receiving, shipping, or transferring items, technology,

software, or information on the EAR Commerce Control List?

[If you need assistance, please call 1+ (260) 387-8293.

To check the list, please see:

http://www.bis.doc.gov/index.php/regulations/export-administration-regulations-ear]

Comments

7. PROJECT TITLE OR EQUIPMENT NAME (IF APPLICABLE):

8. PROPOSED PROJECT DURATION:

From (mm/dd/yy): To (mm/dd/yy):

9. FUNDING

Funding source: WMU proposal number for funded project:

Date of submission to funding agency:

10. SUMMARY OF WORK:

In language understandable to a layperson, summarize primary aims and describe the individual’s research (scope of work) as concisely as possible.

Please provide a list of key words that will help the Export Control Committee classify your technology/item.

Key words:

CERTIFICATION/SIGNATURE

Projects potentially involving technology/information that is export-controlled under either the State Department’s International Traffic in Arms Regulations (ITAR) or the Departments of Commerce’s Export Administrations Regulations (EAR) must be screened by the Export Control committee.

The information contained in this Export Control Compliance Review Worksheet and all required attachments are accurate to the best of my knowledge. All personnel listed recognize their responsibility in complying with federal regulations and the University policies governing the export control. I declare that all research involving this individual will be performed under my supervision.

If during the course of the research conducted by this individual, unanticipated events (in terms of controlled technology security) occur, I will report them to the appropriate federal agency and Export Control Committee immediately.

Forward the Export Control Compliance Review Worksheet to:

Associate Director Research Compliance You may sign, scan, and send as an email

251 W Walwood Hall MS 5456 attachment to:

Western Michigan University

1903 W Michigan Avenue

Kalamazoo, Michigan 49008-5456

You may not proceed until the Export Control Committee has made its final determination regarding the above-mentioned individual.

Furthermore, all future research projects involving this individual, that deviate from the original scope of work, must be submitted to the Export Control Committee for review before you may proceed.

Principal Investigator/Faculty/Host Name Title

Principal Investigator/Faculty/Host Signature Date

Print (Chair, Director, Dean or Associate Dean) Name Title

Signature (Chair, Director, Dean or Associate Dean) Date

Revised 08/24//2017 WMU Export Control (S:\Compliance\Export Control\Application Forms). All other copies obsolete.