ENGLISH PROFICIENCY REPORT
The State University of New York
D
IRECTIONS TO THE STUDENT
1. Complete Part I and address an envelope to the Admissions Office at the SUNY campus you have named in No. 5. It is recommended that
you provide the necessary postage for delivery to the United States.
2
. Take the form and the postage paid envelope to a qualified person (See Part II below for information on qualified persons), and request
that he or she complete Part II and mail the form in the envelope you provide.
1. FAMILY NAME GIVEN NAME(S)
2
. ADDRESS IN HOME COUNTRY NO. AND STREET TOWN OR CITY PROVINCE OR STATE COUNTRY
3. EMAIL 4. TELEPHONE NUMBER
5. NAME AND LOCATION OF CAMPUS TO WHICH YOU ARE APPLYING 6. DATE YOU EXPECT TO COMMENCE STUDIES
M
ONTH: YEAR:
8. ON WHAT DATE WILL YOU TAKE THE TOEFL OR IELTS?
THE STUDENT SHOULD ARRANGE TO HAVE THE SCORES SENT TO THE CAMPUS TO WHICH HE/SHE IS APPLYING.
MONTH: YEAR: LOCATION:
7. HISTORY OF STUDENT’S FORMAL STUDY OF ENGLISH
N
umber of Years Number of Months per Year Number of Hours per Week Native Language of Instructor(s)
SECONDARY SCHOOL
UNIVERSITY
OTHER
P
ART I. (Type directly into the form or print and write clearly in ink)
1. HOW DO YOU KNOW THE STUDENT?
2. HOW LONG HAVE YOU KNOWN THE STUDENT?
(PLEASE PRINT) NAME OF PERSON PREPARING REPORT OFFICIAL POSITION
INSTITUTIONAL AFFILIATION
SIGNATURE OF PERSON PREPARING REPORT DATE
4. PLEASE RECOMMEND AN APPROPRIATE BEGINNING COURSE LOAD AT AN AMERICAN INSTITUTION OF HIGHER EDUCATION FOR THIS STUDENT:
■
Needs no additional language training; could carry a full academic program
■
Needs no special coursework, but could require occasional assistance
■
Needs a short-term intensive English program prior to starting academic coursework
■
Needs one semester or more in an intensive English language program
■
Is unqualified for academic work
3. PLEASE ‘X’ THE APPROPRIATE BOXES TO INDICATE YOUR OPINION OF THE STUDENT’S PRESENT ABILITY IN ENGLISH FROM THE STANDPOINT OF THE LANGUAGE
PROFICIENCY USUALLY NEEDED FOR EFFECTIVE PURSUIT OF STUDIES AT A COLLEGE OR UNIVERSITY IN THE UNITED STATES.
Speaks English:
■
Fluently
■
With ease, but with
■
At an elementary level
■
No ability
some hesitation
Understands spoken English:
■
Excellent comprehension
■
Good comprehension
■
Simple vocabulary only
■
Not at all
Understands written English used in:
■
Advanced level materials
■
Intermediate level materials
■
Elementary level materials
■
No ability
Expresses thoughts in written English:
■
With fluency
■
With ease, but with some
■
On an elementary
■
No ability
grammatical errors level only
PART II. (To be completed by a professor or instructor of English at a school or university or director of an English language program)
The person completing this form should mail it directly to the State University of New York campus to which the student is applying, in a
properly addressed envelope that the student has been instructed to supply. Please feel free to include any other remarks on a separate page.
FSA-3
