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To be completed by supervisor

J·1 scholars must make normal progress in their exchange program and complete all J·1 activities by the end date on their Forms DS-2019. This form is designed to assist you in discussing and evaluating a J·1 scholar's program activities.

Please meet with your ]-1scholar to discuss their progress before completing this form. Email a signed copy of this form, together with a one-page summary outlining the scholar's progress and accomplishment to OIA Director and RO at eric.yang@kysu.edu within 10 business days after receiving an email reminder.

NOTE: Departments should report any changes in a scholar’s J-1 program to OIA immediately for review and approval.

Evaluation period:___(mm/dd/yyyy) to___(mm/dd/yyyy)

Name of J-1 scholar: ___

Program activity: ___

Expected program end date:___(mm/dd/yyyy)

Overall rating: Excellent Good Poor

If poor, describe improvement plans:

Check as applicable to the J-1 scholar:

Yes No Possesses English language proficiency to conduct J-1activities.

Yes No Is making progress toward a timely, satisfactory completion of the J-1 program.

Kentucky State University is an equal educational and employment opportunity/affirmative action institution.

Office of International Affairs Cooperative Extension Building 109

Yes No Has been participating in cultural activities as required by the J-1 federal regulations

No Has been participating in cultural activities as required by the J-1 federal regulations

List of cultural activities:

Supervisor's name___

Title:_____ Department:_____

Email:_____Phone: __________ _____

Signature: _____ Date: _____