Form SV2012-0007 Exchange Student Survey

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Exchange Student Survey
As the program sponsor for the FLEX, YES, and CBYX programs, the Department of State is
responsible for the safety and well-being of our participants. To this end, we would like to hear
directly from you about your experience on program. Please tell us how you are doing by
responding to a brief survey below. We appreciate your help to ensure everyone’s safety and look
forward to hearing from you. If you would like someone from the Department of State to
contact you, please answer “yes” to question number five.

In order for us to better support you, please answer all of the questions in the survey.
OMB Approval Number: 1405-0210
Estimated Burden: 15 minutes
SV2012-0007

1. Please completed the following demographic 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
YES

4. What is the name of your Placement Organization?
ACES
AFS
American Councils
ASSE/World Heritage
AYA/AIFS
AYUSA
Greenheart
CIEE
FLAG
IRIS
BFF
PAX
States 4-H
STS Foundation
ASPECT Foundation
World Link
YFU-USA
NWS

5. Do you have any specific concerns about your placement, health, safety or well-being?
Yes (Someone at the State Department will contact you.)
No (No one will contact you.)
If yes please explain:

6. Do you communicate with your LC/Liaison/Area Representative regularly?
o Yes
o No
7. Does your LC/Liaison/Area Representative help you if you have any problems?
o Yes
o No

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.
o Yes
o No
9. I know how to get emergency help if I need it.
o
o

Yes
No

10. Are you completing a monthly survey from your placement organization (from
someone other than your LC/Liaison/Area Representative)?
o Yes
o No
11. How long did it take you to complete the survey in minutes?
ECA Exchange Student Survey
Paperwork Reduction Act Statement:
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.).
Public reporting burden for this collection of information is estimated to average 15 minutes per response,
including time required for searching existing data sources, gathering the necessary documentation, providing
the information and/or documents required, and reviewing the final collection. You do not have to supply this

information unless this collection displays a currently valid OMB control number. If you have comments on
the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
ECA/PE/C/PY, SA-5, U.S. Department of State, Washington, DC, 20037.
Acronyms:
ACES - American Cultural Exchange Service
AFS - AFS Intercultural Programs
ASSE - International Student Exchange Programs
AYA/AIFS - Academic Year in America/American Institute for Foreign Study
Ayusa - Ayusa International
CCI - Center for Cultural Interexchange
CIEE - Council on International Educational Exchange
FLAG - Foreign Links Around the Globe
IRIS - Iowa Resource for International Service
PAX - Program of Academic Exchange
STS - STS Foundation
YFU-USA - Youth for Understanding USA
BFF- Borderless Friends Forever
NWS-North West Services
FLEX - Future Leaders Exchange
CBYX - Congress Bundestag Youth Exchange
YES - Kennedy Lugar Youth Exchange and Study
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