Form SV2012-0007 Exchange Student Survey

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: 1405-0210
Expires: 06-30-2016
Estimated Burden: 15 minutes
SV2012-0007

Top of Form

1. The following demographic information is optional, however, if you would like someone to contact you or would like to share your experiences, please provide the following information.

Name:

Address:

City/Town:

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

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. Please tell us about your host family experience so far. Are there any concerns you would like to share with us?

6. Do you communicate with your local coordinator regularly and does s/he help you if you have any problems.

7. How is school going?

8. 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

9. Do you have any specific concerns about your placement, health, safety or well-being?

Yes

No

Please explain your answer

10. Do you have a concern and would you like for someone from the Department of State - Youth Programs Division to contact you? If so, please provide the best method and time to contact you and your email address or telephone number.

No, I am fine

Yes, please contact me

Comment

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