Qualtrics Survey | Qualtrics Experience Management

In order to determine if an export license, Technical Assistance Agreement, or other formal agreement will be required for your activity , please provide the following information. The information will be used to classify your item to determine what restrictions may apply and to ensure that none of your collaborators, vendors or end-users are on any of the denied entities list maintained by the US government.

“Exports” include both physical exports of commodities, technical data, or software out of the United States as well as disclosure or transfer of technical data to a foreign person, whether in the U.S. or abroad.

What is your email address?

A copy of this completed worksheet will be sent to the email address provided.

What are the items being exported?

Provide as much information as possible so that the items can be properly classified.

Where is it going?

Provide as much information as possible, including name of institution(s) and mailing address of institutions receiving the item. If the item is to be re-exported by the initial recipient, list ALL of the recipients.

Who will receive it?

Please be specific, and include the name and title of individual(s) receiving the shipment. In order to screen against the various denied entities lists, the name of both the institution and the individual receiving the export must be provided.

How will the item be used by the recipient?