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Academic Institution or English Language School Template
I verify that _________________________________________ possesses sufficient
Student’s Name
proficiency in English language, including listening, reading, writing, and speaking, to do
the following:
 Yes ☐ No
Perform their J-1 activities or complete their academic programs;
 Yes ☐ No
Navigate daily life in the U.S;
 Yes ☐ No
Read and comprehend program materials;
 Yes ☐ No
 Yes ☐ No
Understand fully their rights, responsibilities, and
protections; and
Know how to get help if necessary.
I verify that I am qualified to make an accurate evaluation of this student’s English
language proficiency based on the following:
 I am an English language instructor.
 Admission to our university requires evidence of English language proficiency.
 Course instruction at current institution is conducted in English.
 Other _____________________________________________________________
__________________________________________________________________
Name of the Evaluator: __________________________________________________
Institution:
___________________________________________________
Position Title: ___________________________________________________
Email Address: ___________________________________________________
Signature: __________________________________ Date: _______________