SV-2012-0007 International Exchange Student Survey

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Exchange Student Survey
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In order for us to better support you, please answer all of the questions in the survey.
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Estimated Burden: 15 minutes
SV2012-7

*1. Please fill in the information about yourself below. (mandatory)
Name:
Address:
City/Town:
State:

-- select state --

ZIP:
Home country
Email Address:
Phone Number:

2. Other Information
Host family
Surname:
Name of Local
Coordinator:

3. Please choose the program you are sponsored by.
 FLEX




 CBYX




 ASMYLE




 YES





4. What is the name of your Placement Organization?
 ACES



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 AFS




 American Councils




 ASSE/World Heritage




 AYA/AIFS




 Ayusa




 CCI




 CIEE




 FLAG




 IRIS




 Northwest Services




 PAX




 States 4-H




 STS Foundation




 World Learning




 World Link




 YFU-USA




 Other





If Other (please specify)

5. 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





Please explain your answer

6. 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

7. 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

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

Please explain your answer

9. I possess emergency phone numbers for my local representative, the national office of my

placement agency, my health insurance provider, and the Department of State. I know how to
get emergency help if I need it.
 Yes




 No





Please explain your answer

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

Please explain your answer

11. 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

12. How long did it take you to complete the survey in minutes?

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 Excahnge Service
AFS - AFS Intercultural Programs
ASSE - International Student Exchange Programs
AYA/AIFS - Academic Year in America/American Institute for Foreign Study
Ayusa - Ayusa International
CCI - Center for Cultural Interexchange
CIEE - Council on International Educational Exchange
FLAG - Foreign Links Around the Globe
IRIS - Iowa Resource for International Service
PAX - Program of Academic Exchange
STS - STS Foundation
YFU-USA - Youth for Understanding USA
FLEX - Future Leaders Exchange
CBYX - Congress Bundestag Youth Exchange
ASMYLE - American Serbia and Montenegro Youth Leadership Exchange
YES - Kennedy Lugar Youth Exchange and Study

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