Form SV-2010-0021 Iraqi Young Leaders Exchange Program (IYLEP) Pre-Program

Iraqi Young Leaders Exchange Program
[Insert Year] Pre-Program Survey

	Please know that your answers will be strictly confidential and will in no way affect your participation in the program. We will use the data for analytical and evaluative purposes only. Please feel free to give us your honest opinions. This survey is not a test, and there are no right or wrong answers. Thank you for your participation in this survey.

	Privacy Act and Paperwork Reduction Act Statements: The information solicited on this survey is requested pursuant to the Government Performance and Results Act of 1993 (P.L. 103-62) and the Mutual Educational and Cultural Exchange Act of 1961, as amended, also known as the Fulbright-Hays Act (22 U.S.C. 2451, et seq.). In order to ensure that the U.S. Department of State’s international exchange programs meet statutory program requirements (22 U.S.C. 2460(c)), the Department’s Bureau of Educational and Cultural Affairs (ECA) regularly monitors the programs, gathers data about program accomplishments, and evaluates selected ones. ECA uses the information collected to inform program design, management, and funding. All personal information that is collected through surveys is considered confidential. All responses are coded to ensure the confidentiality of individual responses. Data collected under this study will not be shared, sold, or used for fundraising purposes. Survey data and findings will be used only in an aggregate form for the express purposes of fulfilling the data needs of the outcome assessment. Responses to this survey are voluntary. Public reporting burden for this collection of information is estimated to average twenty (20) minutes to respond to this survey, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An Agency may not conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to: A/ISS/DIR, U.S. Department of State, Washington, D.C. 20520.

1. Please identify your exchange group:

[Insert Group 1]
[Insert Group 2], etc.

	2. In your own words, what do you hope to achieve by coming to the United States and participating in the Iraqi Young Leaders Exchange Program? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

3. There are many different reasons for participating in the exchange program. In the table below, please identify your three most important reasons for participating.

To gain experience and knowledge about leadership
To learn about community development (how to improve my neighborhood and community)
To increase my understanding of the United States, American society, people, and culture
To learn about government in the United States
To make friends with American students and their families
To make friends with other Iraqi participants in the program
To share my culture with others
To represent my country abroad
Other (Please write in): ___________________________________

4. Please rate yourself on the following abilities. Please check one box in each row.

	Poor	Fair	Good	Excellent
Being self-reliant, being independent, relying on yourself
Speaking in public
Listening to other people's suggestions or concerns
Expressing ideas and feelings
Being tolerant (respectful) of others different than you
Leading a team and motivating others
Being flexible
Solving problems
Planning for the future
Managing your time
Managing money
Discussing your beliefs/values
Willing to make changes in your community

5. How much do you agree/disagree with the following statements as they relate to you as an individual? Please check one box in each row.

	Strongly Disagree	Somewhat Disagree	Neither Agree Nor Disagree	Somewhat Agree	Strongly Agree
I feel I have many choices in my life
I feel I can make a difference in my family
I feel I can make a difference in my community
I feel I can influence people around me

6. Please rate your current knowledge and understanding of the following topics and themes highlighted in your Iraqi Young Leaders Exchange Program. Please check one box in each row.

	No Knowledge	Less Than Basic	Basic Knowledge	Beyond Basic	Advanced Knowledge
Leadership
Community service (for example: people helping others in their neighborhood, community, or local organization)
Community Development (for example: people working together to improve their neighborhood and community)
Local government (for example: government in individual provinces, districts, towns or villages)

	7. What does community service mean to you? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

8. Please rate your knowledge or understanding of the following topics. Please check one box in each row.

	No Knowledge	Less Than Basic	Basic Knowledge	Beyond Basic	Advanced Knowledge
United States democracy
United States economy
United States values and culture
Religious and ethnic diversity in the United States
Freedom of speech and press in the United States
Voluntary community service in the United States
Daily life in the United States

9. How do you view the United States government and the American people? Please check one box in each row.

	Strongly Unfavorable	Generally Unfavorable	Neither Favorable Nor Unfavorable	Generally Favorable	Strongly Favorable
United States Government
American people

10. How do you view the United States government and its relationship with your home country?

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
The United States Government is a trustworthy partner for my country

	11. What is the first positive thing you think about when you think about the United States? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

	12. What is the first negative thing you think about when you think about the United States? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

13. Which of these fields are you considering studying or working in when you graduate from high school? Please check one box.

Agriculture
Arts and Humanities (history, languages, literature, art, theater)
Athletics
Business Administration, Finance
Computer Science, Information Technology
Education
Engineering
Environment
Government
Humanitarian Affairs, Development Assistance, Conflict Resolution
International Relations
Labor, Trade Unions
Law, Judicial, Law Enforcement
Library and Information Science
Media, Mass Communications, Journalism, Communication Technology, Advertising, Graphics
Medicine
Military Service
Public Administration
Public Health
Religion
Science (physics, math, chemistry, biology, astronomy, geography, agronomy)
Social Sciences (sociology, economics, psychology, political science)
Social Work
Teaching English, English language instructions
Not Sure
Other (Please write in): ___________________________

14. Which best describes the geographic location where you live. Please check one box.

My country's capital city
Another major city in my country other than the capital
A small city, town, or rural location in my country

15. Age: [Drop-down list]

16. Gender:

Female
Male

17. Which religion do you most closely identify with? Please check one box.

Baha'ism
Buddhism
Christianity (for example: Orthodox, Catholic, Protestant)
Confucianism
Hinduism
Islam
Jainism
Judaism
Shintoism
Sikhism
Taoism
Zoroastrianism
None
Other (Please write in): _______________________________

	18. Thank you for completing this survey! If you have additional comments you would like to make, about any of the things above, about your participation so far, about what you have been proud to share, or something we have not touched upon, please do so here. We value your thoughts very much. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

	19. How long did it take you to complete this survey?________ Minutes

1 SV-2010-0021

OMB No.: 1405-0158

Expiration Date: 04/30/2011

Estimated Burden Time: 20 minutes