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The remaining questions are to be completed by the interviewer

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Applicant’s name
Interviewer’s name
Date

Question	Answer	Interviewer Notes Please check the box that apply
Why do you want to work in U. S. A?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What would you need in order to enjoy your time in the U. S. A?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe your plans for the future. What are your goals?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe your general health.		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Have you ever suffered from or sought treatment for depression, alcoholism, drug addiction or an eating disorder? Please explain.		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Has anyone in your family suffered from depression or alcoholism? Please explain.		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe any history of Job abuse in any company you have previously worked?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe where you were born and raised		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Do you have any siblings? If so, how old are they?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe the relationship you have with your siblings.		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences

How often do you have contact with your family members?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Describe your family’s support of your decision to work in U. S. A		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What is your family’s reaction to you spending a year away from home?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
How were you disciplined as a child?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
When, where and for how long have you spent time away from home?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
When, where and for how long have you traveled in English-speaking countries?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Are you willing to be placed with a Company that is of a different religion? How would you accommodate?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What is your favorite area of study? Why do you like it?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What did you like about your last Job experience? What did you dislike about it?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
Where and when did you complete any formal English courses?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What volunteer work have you done?		Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences

How will you adjust to a new company, country and culture?				Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
How much notice do you require before leaving for a placement with your company?				Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
				Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
What problems do you anticipate while working in your previous job?				Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
How do you feel about being placed with a Company of a different race or has different political views or beliefs?				Asked me to repeat or rephrase the question Answered with isolated words or small phrases Answered in complete sentences
The remaining questions are to be completed by the interviewer
Please rate the Job Seekers:		Poor Fair Good Excellent Appearance Excellent Self Confidence Excellent Attitude Good Manners Excellent Communication skills Good
English Rating Scale
1 – Uses few or no English words; understands greetings and other basic, memorized phrases. 2 – Uses some English phrases though thoughts may be disconnected; understands basic English sentences when spoken clearly and slowly but relies on body language and facial expressions to determine meaning. 3 – Responds in complete thoughts and has a large vocabulary of everyday common terms. Can perform tasks based on a short series of instructions, takes short time to mentally translate and can understand complex sentences when repeated or rephrased. 4 – Responds in complete sentences and can re-word what he/she is saying when the meaning is unclear or when he/she cannot remember unusual vocabulary words. Can perform tasks based on complex instructions and understands others when they are speaking at a natural rate. 5 – Responds completely with more descriptive language and does not take time to mentally translate when listening or speaking. Understands conversations about abstract things.

Based on the table above, please rate the applicant’s ability both to speak and comprehend English. Briefly explain your decision.		Rating: Native Explanation:
This applicant will make a good staff workers for the following reasons:
What difficulties will the applicant experience while placed working in a foreign country?
Interviewer’s signature
Date

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