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.}
*****************************************************************
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
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