J1 Academic Training Self-Evaluation

This form is used to report on your academic training experienece as required by the U.S. Department of State.

Confirmation of Name and Contact Information

Last Name

First Name

Email Address

ACU ID

Please list your residential address.

Country

Street

City

Region

Postal Code

What's your telephone number?

Marital Status

Single

Married

Academic Training Details

Employer's Name

Academic Training Start Date

Academic Training End date

How effective has your J-1 Academic Training been in meeting the goals and objectives for this specific training program?

Very Effective

Somewhat Effective

Not Effective

Please explain and give examples for the reason you selected the rating above.

How has your academic training experience built upon the skills and knowledge you acquired in your coursework at ACU?

Additional Comments

Emergency Contact Information

Has your emergency contact information changed?

If your information has changed, select "yes" and list the new information, including name and telephone number of the new emergency contact.

Yes

No

Please list the name and telephone number of the new emergency contact.

By typing my name below, I certify that the information provided in this form are known to be true and correct to the best of my knowledge.

PLEASE ELECTRONICALLY SIGN BELOW THAT YOU UNDERSTAND THE ABOVE STATEMENTS.

Electronically sign your name below:

Thank you for your submission. If you have further questions or comments, please reach out to Lucy Dawson at 325-674-2237.