ADVISING/INFORMATION CENTER STATISTICS

The Department of State's Educational Information and Resources Branch (ECA/A/S/A) has compiled this survey form as a model to assist educational advisers in collecting data from students receiving visas for study in the U.S. It is based on forms currently in use by advising centers in Malaysia, India, Nepal and Ghana. It is intended strictly as a model and will most likely need to be modified according to specific circumstances in each country and edited for appearance and ease of use. ECA/A/S/A is indebted to the Regional Educational Advising Coordinators for East Asia, Dr. Marti Thomson, and for Africa, Ms. Nancy Keteku, as well as to the U.S. Educational Foundations in India and Nepal.

The importance of and methods for collecting this data were discussed in two cables, STATE 032110, dated February 21, 1997, and USIA 07254, dated April 9, 1997. The form is intended to be distributed by consular officers to visa recipients, who should fill out forms and deposit them in a conveniently located spot. Advising center personnel arrange with the Public Affairs Section of the appropriate U.S. embassy for regular collection of the forms and ensure that consular officers have an adequate supply of forms available.

It is important to ask only those questions that elicit information that can reasonably be collated and analyzed. In countries where there is more than one active advising center, arrangements should be made for one center to serve as central collector and analyzer of data. Advisers enter the data in a database and produce a summary written report distributed to interested parties, such as the Public Affairs Section, ECA/A/S/A and appropriate ministries.

Good luck in your efforts; please contact us if you have questions or suggestions.

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STUDENT INFORMATION FORM - QUESTIONNAIRE
This questionnaire has been designed to obtain statistical information on students receiving visas for advanced studies in the United States. The information that you, and others like you, provide will be used to assist future students in making realistic decisions concerning choice of universities, financial aid, and so forth. This information will give us a profile of students served and help in the overall improvement of our program. This questionnaire is strictly confidential and voluntary; however, we urge you to provide this invaluable information and assist countless other students going abroad. We further hope that you will maintain contact with {Advising center office} while abroad and on your return home. We will be happy to have you participate in our advising programs and share your experiences with our staff and other interested students. The information you provide is confidential and only for the use of the Consular office and the State Department-affiliated educational advising center. Thank you.

I. TODAY'S DATE: _________________________

II. PERSONAL DATA
Name: _______________________________________________________
Last - First - Middle
Other names used: _________________________________________
Date of Birth: (Month/Day/Year) ___________________________
Sex: M _____ F ______
Home address: ______________________________________________
____________________________________________________________
Telephone number: __________________________________________
Identification number {such as national i.d. or advising center tracking number}: __________________________________________
Ethnicity {if appropriate}: ________________________________

III. EDUCATIONAL BACKGROUND

Previous University Experience - universities attended; degrees earned; dates; including transfer information {may wish to use ladder format}

Scores of tests taken:

TOEFL _______
SAT: V- ______ Q- ______
GRE _______
GMAT _______
ECFMG _______
CGFNS _______
NATIONAL EXAMS (NAME)_________________(SCORE)________
OTHER (NAME) _____________________ (SCORE) ______

IV. INFORMATION PERTAINING TO U.S. STUDIES
Name and Location of the U.S. academic institution you will attend:
_______________________________________________________________

Level of Admission:

Vocational ______
Associate ______
Bachelor ______
Master ______
Doctoral ______
Training ______
Seminar ______
Other ______
Subject and Specialization: _________________________________
Status:

New Student - Date entering
Returning Student to Same University - Dates Attended
Returning Student to Different University - Dates Attended
Your field of study: _________________________________________
{May be helpful to list most popular fields, plus "other" category}
Your educational goals and career plans:_______________________________

Sources of funds for your U.S. study (Check all that apply):

U.S. government _____
U.S. institution scholarship or aid_______ {type, amount}
Family in home country ______
Family in U.S. _______
Private U.S. Sponsor ______
Foundation/International Organization _________
Agency Sponsor ______
Home Government/University _______
Bank loan ______
Current Employment _______
Other (Specify)____________________________________
Primary source of funds for your U.S. study (Check only one):
U.S. government _____
U.S. institution scholarship or aid_______ {type, amount}
Family in home country ______
Family in U.S. _______
Private U.S. Sponsor ______
Foundation/International Organization _________
Agency Sponsor ______
Home Government/University _______
Bank loan ______
Current Employment _______
Other (Specify)____________________________________

Type of visa you have been issued:
F-1 _______ J-1 _______ M-1 _______

V. SOURCES OF INFORMATION ON U.S. STUDY:

Which of the following resources were helpful to you in seeking admission to a U.S. institution?

The {name} advising center ___________ {list all within USIA network}
Private advisory service _______________ {name}
Friend or relative in home country who has studied in U.S. ___________
Friend or relative in the U.S. _____________
Other ________________________________
{Advisers may want to follow up this item with a question detailing whether the student used advising center services via mail, phone, e-mail, internet or walk-in.}
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Form revised on (date)
{Name of Advising Center or U.S. embassy; contact information}

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Please send comments to [email protected].

For further information, contact:
Educational Information and Resources Branch
U.S. Department of State SA-44
301 4th Street, SW Room 349
Washington, DC 20547
tel: 202-619-5434
fax: 202-401-1433