Form SV-2012-0010 U.S. Exchange Student Survey

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U.S. Exchange Student Survey
Thank you for helping us!
In order for us to better support you, please answer all of the questions in the survey.
OMB Approval Number: xxxx-xxxx
Expires: xx-xx-xxxx
Estimated Burden: 15 minutes
SV2012-10

*1. Please fill in the information about yourself below. (mandatory)
Name:
Email Address:

2. What is your host country?
City/Town:
Country:

3. Other Information
Host family Surname
(if applicable):
Name of Local
Coordinator/Resident
Director:

4. Choose the program you are sponsored by.
 Yes Abroad




 CBYX




 NSLI-Y





5. What is the name of your Placement Organization?
 ACES
















AFS Intercultural Programs

 American Councils




 ASSE - Give e.V.



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 CIEE - Experiment e.V




 FLAG - Partnership International




 YFU-Germany




 APSA




 University of Delaware




 Russian American Foundation




 Amideast




 iEARN




 Legacy International




 Other





If Other (please specify)

6. I am comfortable talking with my host family, and they help me whenever I have a problem
or concern.
 Agree




 Neither Agree or Disagree




 Disagree




 Not Applicable





Please explain your answer

7. I communicate with my placement organization’s local representative.
 Less often than once per month




 Once per month




 More often than once per month





Please explain your answer

8. I have a good relationship with my local representative, and I receive adequate support
from him/her.
 Agree




 Neither agree or disagree




 Disagree





Please explain your answer

9. I am adapting well to my school and new friends.
 .Agree




 Neither Agree or Disagree




 Disagree





Please explain your answer

10. I possess emergency phone numbers for my local representative, the national office of
my placement agency, my health insurance provider, and the US Embassy or Consulate in
my host country. I know how to get emergency help if I need it.
 Yes




 No





Please explain your answer

11. Do you have any specific concerns about your placement, health, safety or well-being?
 Yes




 No





Please explain your answer

12. If you have a concern and would you like for someone from the Department of State Youth Programs Division to contact you, please provide the best method and time to contact
you, and your email address or telephone number.
 via email




 via telephone





Comment

13. How long did it take you to complete this survey?

ECA Exchange Student Survey
Paperwork Reduction Act Statement:

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.).
Public reporting burden for this collection of information is estimated to average 15 minutes per
response, including time required for searching existing data sources, gathering the necessary
documentation, providing the information and/or documents required, and reviewing the final
collection. You do not have to supply this information unless this collection displays a currently valid
OMB control number. If you have comments on the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to: ECA/PE/C/PY, SA-5, U.S. Department of
State, Washington, DC, 20037.
Acronyms:
ACES - American Cultural Exchange Service
AFS - AFS Intercultural Programs
Amideast - America and Mideast Educational and Training Services
APSA - Americans Providing Study Abroad
ASSE - International Student Exchange Programs
CIEE - Council on International Educational Exchange
FLAG - Foreign Links Around the Globe
iEarn - International Education and Resource Network
YFU-USA - Youth for Understanding USA
CBYX - Congress Bundestag Youth Exchange
NSLI-Y - National Security Language Initiative for Youth
YES - Kennedy Lugar Youth Exchange and Study

Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 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.).
PURPOSE: The information solicited on this survey is necessary to determine the safety and wellbeing of high school exchange students on U.S. Department of State-sponsored programs outside of
the United States. The results of the survey will be used to determine if the students require
additional assistance or have questions that they need answered. The information furnished may
also be used to ask additional follow-up questions relating to the answers provided.
ROUTINE USES: The information on this survey helps to effectively administer Department of Statesponsored exchanges for U.S. high school students, including the ability to review complaints about
the programs. The information will not be shared outside the Department of State unless there is an

issue regarding a respondent’s safety or well-being, or sharing is required by legal authorities. In
these cases the Department may share the information with a respondent’s Placement Organization
and possibly the natural family. The information provided may also be released to federal, state,
local, or foreign government entities for law enforcement purposes. More information on the Routine
Uses for the system can be found in System of Records Notice, State-08, Educational and Cultural
Exchange Program Records.
DISCLOSURE: Providing this information is voluntary.

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