Applicant’s Full Name:

Present Contact Address:

Passport Number:
Marital Status:
Contact Telephone:
Post / Position Offered:
Job Reference #:
Contact Email Address:
Nationality:

Question Answer Interviewer Notes

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

 Asked me to repeat or rephrase the

How often do you have contact with question
your family members?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
Describe your family’s support of question
your decision to work in the USA.  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
What is your family’s reaction to you question
spending a year away from home?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
How were you disciplined as a child? question
 Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
When, where and for how long have question
you spent time away from home?  Answered with isolated words or small
phrases
 Answered in complete sentences

 Asked me to repeat or rephrase the

When, where and for how long have . question
you traveled in English-speaking  Answered with isolated words or small
countries? phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
Are you willing to be placed with a question
Company that is of a different  Answered with isolated words or small
religion? How would you phrases
accommodate?  Answered in complete sentences
 Asked me to repeat or rephrase the
What is your favorite area of study? question
Why do you like it?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
question
What did you like about your last Job  Answered with isolated words or small
experience? What did you dislike phrases
about it?  Answered in complete sentences
 Asked me to repeat or rephrase the
Where and when did you complete question
any formal English courses?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
What volunteer work have you question
done?  Answered with isolated words or small
phrases
 Answered in complete sentences

 Asked me to repeat or rephrase the

How will you adjust to a new question
company, country, and culture?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
How much notice do you require question
before leaving for placement with  Answered with isolated words or small
your company? phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
What problems do you anticipate question
while working in your previous job?  Answered with isolated words or small
phrases
 Answered in complete sentences
 Asked me to repeat or rephrase the
How do you feel about being placed question
with a Company of a different race  Answered with isolated words or small
or has different political views or phrases
beliefs?  Answered in complete sentences

The remaining questions are to be completed by the interviewer

Poor Fair Good Excellent

Please rate the Job Seekers: 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 incomplete thoughts and has a large vocabulary of everyday common terms. Can perform tasks based on a short
series of instructions, takes a 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 Rating: Native
ability both to speak and comprehend English. Briefly
explain your decision. Explanation:

This applicant will make good staff workers for the

following reasons:

What difficulties will the applicant experience while

placed working in a foreign country?

Interviewer’s signature

Date