Form DS-573 Overseas School Questionnaire

OMB APPROVAL NUMBER XXXX-XXXX
EXPIRATION DATE XX/XX/XXXX
*ESTIMATED BURDEN: 15 MINUTES

U.S. Department of State

OVERSEAS SCHOOLS QUESTIONNAIRE
This questionnaire should be completed in cooperation with the local Foreign Service post by those overseas schools which have received assistance
under the Overseas Schools Program in the past and/or desire to request assistance under that Program. The educational programs of schools requesting
assistance should meet the policies and criteria for assistance set out in 2 FAM 600. The information for completing this questionnaire should be provided
by the chief administrative official of the American-sponsored school at post. It should be reviewed by the governing board of the school and by the
responsible officials at the post prior to transmittal by the post to the Department, Subject ASCH: Overseas Schools. In order that information from various
posts may be comparable, all data should be as of September 15. Submit original and one copy by December 15. Completion of this form is voluntary.
Post

Date Report Prepared by School (mm-dd-yyyy)

I. GENERAL INFORMATION
1. Name of School Association
2. Name of School
3. Local Address of School

3a. Telephone Number

4. Mailing Address of School to be Used by U.S. Correspondents (Address will be published in the A/OPR/OS directory.)
5. Name and Title of School Administrator

5a. Home Telephone Number

6. Name and Title of Person Preparing Report

6a. Signature

7. Name and Title of Governing Board Official Reviewing Report

7a. Signature

8. Name and Title of Official at Foreign Service Post Responsible for Coordinating Post's
Interest in School Activities

8a. Signature

9. Indicate grades included in the school.

9a. Does the school offer boarding facilities?
Yes
No
If Yes, what grade levels?

10. Indicate School Organization
a. Elementary includes grades

through

.

b. Intermediate includes grades

through

.

c. High School includes grades
through
.
(If other names are used such as "Lower School," "Junior High School," "Primary," etc., please substitute the proper name. If one or more categories do
not apply, leave blank.)

11. Indicate grades in which supervised correspondence work is offered in lieu of regular instruction.
12. Enclose list of special education services offered by school or within community (i.e., learning disabilities, remedial reading, speech therapy,
ESL, blind, deaf, etc.).
13. Give opening and closing dates of each school term. (Attach copy of complete school calendar, including holidays.)

13a. Give total number of days of instruction, excluding holidays.
14. Is the school accredited by a U.S. regional accrediting agency?

Yes
No
If yes, give name of accrediting organization and date of accreditation. If No, what steps have been taken toward securing accreditation?

15. Is the school accredited or approved by local authorities? Describe nature of accreditation, or approval, including name(s) of Ministry or other
authority.

16. If there have been any amendments, additions, or deletions from the school's constitution and bylaws, kindly enclose copies of the revised
documents.
17. Kindly enclose a copy of the most recent edition of the school's catalog and curriculum guides for each grade level.
DS-573
*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching existing data
XX-XXXX
sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this estimate of
the burden and recommendations for reducing it to

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II. GOVERNING BOARD OF THE SCHOOL
1. Official Name of the Governing Board

2. List members of the governing board according to the following form.
Position On
Board

Name

Regular Work Affiliation
(See note for code)*

Nationality

Date Term Began
(mm-dd-yyyy)

Date Term Expires
(mm-dd-yyyy)

* Insert the name of business or firm, foundation, government, or other organization with which the Board Member is affiliated. (For U.S. Government
personnel, include position title.) After the name, use the following symbols to identify work affiliation: A-U.S. Government; B-Host Government; C-Third
Country Government; D-Business Firm; E-Other. If the Board Member is a dependent with no work affiliation in his/her own right, use above
identification but add spouse or other pertinent identification. Kindly advise A/OPR/OS of changes in Board membership as they occur.

III. STUDENT BODY
1. Identify students enrolled as of September 15 according to the following categories. (Ensure components add to proper totals.)
A. U.S. Citizens
A-1. Dependents of direct-hire U.S. Government employees, except Department of Defense
Provide breakdown:

U.S. Department of State

Peace Corps

Dept. of Agriculture

Dept. of Commerce

Total: Group A

Others (Identify)
Subtotal: A-1
A-2. Dependents of Department of Defense employees, including civilian employees
Provide breakdown:
Other: Army Forces

Military Attaches
Navy Forces

MAAG
Air Forces

Subtotal: A-2

A-3. Dependents of personnel contracted to U.S. Government Agencies
Provide breakdown by U.S. agency sponsoring contract and identify by business firm or institution:

Subtotal: A-3
A-4. Dependents of other U.S. citizens (Do not include dependents of U.S. Government employees.)

Subtotal: A-4

B. Host Country Nationals
Total: Group B
C. Third Country Nationals
Total: Group C

Attach list providing breakdown of number of students by country.
D. Total Enrollment
Total Enrollment (A+B+C)
DS-573
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.
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2. Show numbers of students by grade according to the six categories in Part III.
CATEGORIES
GRADE

A-1

A-2

A-3

A-4

B

C

TOTAL

K
1
2
3
4
5
6
7
8
9
10
11
12
TOTAL
3. Show number of students receiving scholarship aid according to following tabulation.
HOST COUNTRY NATIONALS
GRADE

U.S. Government
Sponsored

School Sponsored

U.S. NATIONALS

THIRD COUNTRY
NATIONALS

School Sponsored

School Sponsored

TOTAL

K
1
2
3
4
5
6
7
8
9
10
11
12
TOTAL
4. Please provide the following information concerning expenditures for scholarships. (Explain in terms of U.S. dollars.)
a. Expenditures financed from U.S. Government grants

$

b. Expenditures from school budget excluding U.S. Government grants

$

c. Total expenditures for scholarships

$

IV. SCHOOL FINANCES
1. Provide annual tuition rate(s) for the current school year, expressed in terms of U.S. dollars. Identify grade(s) to which each rate applies, if there
is more than one rate. If there are boarding fees, list separately. Enclose copy of schedule of fees.

2. May tuition be paid in U.S. dollars?
received in U.S. dollars?

If yes, approximately what percentage of the school's total tuition is
Percent

3. Does the school assess a capital levy fee, enrollment fee, or similar charge to guarantee space in the school?
If so, kindly enclose descriptive information (or note where to find in school catalog).
DS-573
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Yes

No
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