Statement of English Proficiency for Inbound Student s Full Name NOTE U S Department of State regulations require that an exchange visitor possesses sufficient proficiency in the English language as determined by an objective measurement of English language proficiency successfully to participate in his or her program and to function on a day to day basis A sponsor must verify an applicant s English language proficiency through a recognized English language test by signed documentation from an academic institution or English language school or through a documented interview conducted by the sponsor either in person or by videoconferencing or by telephone if videoconferencing is not a viable option Please answer these questions as honestly as you can Ask your language teacher or another school official with a knowledge of English to also make an assessment of your language proficiency This form must be completed and returned before you can be issued a VISA Conversational Spoken English Check only one box in each column Teacher Evaluation Self Evaluation I speak English as my native language I come from an area where English as a second language is in common use and I speak it regularly at school or at home I have studied English and have associated with English speaking people enough to know that I can carry on a good conversation in English I have studied conversational English but speak it in a rather halting manner I have studied English but my conversation is very slow I must have many terms words explained to me I have studied conversational English some but I cannot carry on a conversation I have not studied conversational English and know only a few words I cannot speak any English but will enjoy the challenge of learning it Written English Check only one box in each column Teacher Evaluation Self Evaluation English is my native language and I read and write it well My country is bilingual Reading and writing English is common for classes in my school I have studied English and I am proficient in reading and writing it I have studied English I understand most of what I read without the help of other people or a dictionary I have studied English a little but must work very hard to understand written words or phrases I do not read or write English Please return this signed form to your Hosting Rotary District and attach documentation of any English classes you have taken outside of school such as private tutoring Student Signature Print Name Date Teacher s Signature Teacher s Name Title Home Country Home Rotary District DOCUMENT RETENTION TRACKING INSTRUCTIONS Appropriate District or Club Officer must upload a digital copy in the YEAH online database Records will be maintained for a minimum of three years after Exchange completion Orig 02 23 2015
Statement of English Proficiency for   Inbound Student   s Full Name   NOTE  U S Department of State regulations require t...