Form SV-2010-0026 International Visitors Leadership Program (IVLP) � Pre-P

International Visitors Leadership Program (IVLP) –
[Insert Year] Multi-Regional Projects
Pre-Program survey

	As you begin your program, we would like to ask you a few questions about your anticipated program experience, opinions, and future plans. The purpose of these questions is to help us understand the diverse characteristics and opinions of our program participants. All responses will be kept confidential and no one else will have access to them. Your answers will not be attributed to you. This survey is not a test and there are no right or wrong answers. However, we do need your feedback in order to make informed decisions regarding program improvements, so please give us your thoughts and opinions. We will use the data for analytical and evaluative purposes only. Thank you, in advance, for your participation! We wish you a wonderful program experience.

Privacy Act and Paperwork Reduction Act Statements:

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.). In order to ensure that the U.S. Department of State’s international exchange programs meet statutory program requirements (22 U.S.C. 2460(c)), the Department’s Bureau of Educational and Cultural Affairs (ECA) regularly monitors the programs, gathers data about program accomplishments, and evaluates selected ones. ECA uses the information collected to inform program design, management, and funding. All personal information that is collected through surveys is considered confidential. All responses are coded to ensure the confidentiality of individual responses. Data collected under this study will not be shared, sold, or used for fundraising purposes. Survey data and findings will be used only in an aggregate form for the express purposes of fulfilling the data needs of the outcome assessment. Responses to this survey are voluntary.

Public reporting burden for this collection of information is estimated to average five (5) minutes to respond to this survey, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An Agency may not conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to: A/ISS/DIR, U.S. Department of State, Washington, D.C. 20520.

1. Which IVLP group are you participating in?

[Insert Project Name 1]
[Insert Project Name 2]
[Insert Project Name 3], etc

2. There are many different reasons for participating in the IVLP program. From the list in the table below, please identify your three most important reasons for participating.

To increase my understanding of the United States, American society, the American people, and American culture
To meet my counterparts in the United States
To meet my counterparts from other countries participating in the program
To learn about recent trends and practices in my field
To establish relationships with my counterparts from the United States
To establish relationships with my counterparts from other countries
To establish networks with counterparts in the United States and other countries
Other (Please write in): _________________________________________

	3. Could you please elaborate on your primary goals for participating in this exchange? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

4. Please rate your knowledge or understanding of the following topics. Please check one box in each row.

	No Knowledge	Less Than Basic	Basic Knowledge	Beyond Basic	Advanced Knowledge
United States democracy
United States economy
United States values and culture
Religious and ethnic diversity in the United States
Freedom of speech and press in the United States
Voluntary community service in the United States
Daily life in the United States

5. How do you view the United States government and its relationship with your home country?

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
The United States government is a trustworthy partner for my country

6. How do you view the United States Government and the American people? Please check one box in each row.

	Strongly Unfavorable	Generally Unfavorable	Neither Favorable Nor Unfavorable	Generally Favorable	Strongly Favorable
United States Government
American people

7. What is your field of work? Please check all boxes that apply.

Agriculture
Athletics
Arts and Humanities (history, languages, literature, art, theater)
Business Administration, Finance
Computer Science, Information Technology
Education
Engineering
Environment
Government
Humanitarian Affairs, Development Assistance, Conflict Resolution
International Relations
Labor, Trade Unions
Law, Judicial, Law Enforcement
Library and Information Science
Media, Mass Communications, Journalism, Communication Technology, Advertising, Graphics
Medicine
Military Service
Public Administration
Public Health
Religion
Science (physics, math, chemistry, biology, astronomy, geography, agronomy)
Social Sciences (sociology, economics, psychology, political science)
Social Work
Teaching English, English language instructions
Not Sure
Other (Please write in): _________________________________________

8. Which best describes the geographic location where you live? Please check one box.

My country's capital city
Another major city in my country other than the capital
A small city, town, or rural location in my country

	9. Home country: ____________________________________

	10. Age: ____________________________________

11. Gender:

Female
Male

	12. How long did it take you to complete this survey?  ________ Minutes

1 SV-2010-0026

OMB No.: 1405-0158

Expiration Date: 04/30/2011

Estimated Burden Time: 5 minutes