Application Form
Fulbright-Hays Language and Culture Immersion Program
The purpose of this form is to gather basic information about you, your language background,
and Mandarin language experiences. Please fill it out as completely and accurately as possible.
Information marked with asterisks is required.
A. Basic information
Please answer the questions of gender, birth year, and place of birth, growing place, and native
language.
Basic demographic information
*Name
*Address
*E-mail
Phone
Gender (optional)
Age (optional)
Undergraduate education
*Degree(s)
*Major
*QPA
Institution(s)
Graduate education (if obtained)
*Degree(s)
*Major
*QPA
Cell Phone
*Institution(s)
Language background
*Place of birth (country)
*Place of growing up (country)
Native/first language
*Age of acquisition (A o A) of the native/first
language
*Second/foreign language(s)
*Age of exposure (A o E) to second
language/foreign languages
*Professional background (required)
*Profession/occupation
*Years practicing this profession
*Experiences teaching foreign languages
*Years of experience teaching foreign/second
language(s)
*Experience teaching Mandarin
*Experience in international education (other
than foreign language)
Describe international experience(s)
Other
B. Mandarin language background
Please write the age of beginning Mandarin language learning.
Period of Mandarin experience (if obtained)
*Age of exposure (A o E) to Mandarin
*Did you learn the language in a Mandarin speaking
country/region/other?
* If so, what age did you go to the Mandarin
speaking country/region/other?
Years/months you lived in the Mandarin speaking
region/place. (If not continuous, please indicate the
years that you have stayed in the region/place.)
C. Education
1. Please write information about formal education in the United States and any Mandarin
speaking country/region/place/other you have.
Education of Mandarin (if obtained)
*Years/length of Mandarin formal education in
the United States.
*Is Mandarin spoken at home?
*Have you taken any Mandarin standardized
tests?
Yes _________
No __________
*Language proficiency test score other than HSK.
Test _____________________
Test Score ________________
*Do you have HSK scores? If so, please write your score in the blanks below.
*Test scores
Listening __________________
Speaking ___________________
Reading ___________________
Writing ____________________
Note: The HSK (Hànyǔ Shuǐpíng Kǎoshì) is a standardized test of Chinese language proficiency
for the non-native speaker.
2. Please estimate your ability to speak, understand, read, and write Mandarin. Use the number
scales - 1: very poor, 2: poor, 3: medium, 4: good, 5: very good.
*Proficiency of Mandarin (1–5 points)
1
2
3
4
Speaking
Understanding
Reading
Writing
3. *Mandarin is my native language? ______________ YES _____________ NO
5
4. *Please estimate the amount of Mandarin usage at school, at home, and with friends using
number scales - 1: occasionally, 2: around once a week, 3: many times a week, 4: once a day, 5:
most or all of the time.
*Amount of Mandarin usage (1–5 points)
1
2
At school
At home
With friends
Phone/cell phone/texting
Internet/social networks
Other
5. Please write the amount of hours exposed to Mandarin a week.
*Amount of Mandarin input (hours/week) you currently experience
Classes at school
TV watching
Radio
Movie
Talking with native speakers
Phone/cell phone/texting
Internet/social network
Other
*Total hours of exposure to Mandarin per week
3
4
5
D. Other second/foreign language background
1. Please write the information of other languages other than English and Mandarin. Each
category is the language that you can use, the amount of education, and years of residence in that
country of the language.
*Experience in other languages other than English and Mandarin (if applicable)
Other languages (3nd and 4th)
Language(s)
Years of education in each language
Years of residency in respective
country/region/others
2. *Please estimate your ability to speak, understand, read, and write other languages. Use the
number scales - 1: very poor, 2: poor, 3: medium, 4: good, 5: very good, or 6: native proficiency.
*Proficiency of other languages (1–6 points) (if applicable)
1
Language 3rd :
Speaking
Understanding
Reading
Writing
Language 4th:
Speaking
Understanding
Reading
Writing
2
3
4
5
6
E. Familiarity using computers
1. Have you used a computer mouse and keyboard before? If so, please estimate your familiarity
with the use of these items. Use the number scales - 1: very poor, 2: poor, 3: medium, 4: good, 5:
very good.
Famil *Familiarity with use of a computer mouse and a keyboard (1–5 points)
1
2
3
4
5
Famili * Familiarity
2. Have you use a computer mouse and keyboard in Mandarin? If so, please estimate your
familiarity with the use of these items. Use the number scales - 1: very poor, 2: poor, 3: medium,
4: good, 5: very good.
Famil *Familiarity with use of a computer mouse and a keyboard (1 – 5 points)
1
Famili
2
3
4
5
*Familiarity
F. Master’s degree in education and New York State Mandarin teaching certification
program
The Department of Learning and Instruction of the Graduate School of Education at the
University at Buffalo is planning to begin the implementation of a master’s degree in education
leading to New York State Mandarin teaching certification program in the near future.
Will you be interested in receiving additional information about this program?
Yes _______________ No ________________
G. Research Study
A small-scale research study was integrated in the project design. The purpose of the small-scale
study is to investigate the effects of this short-term foreign language and culture immersion
program on elements of the participants’ linguistic ability, cognitive growth, and socio-cultural
aspects. It will explore the extent that participants improve the Mandarin language proficiency,
cultural understanding of the Chinese culture and perception of the people. In addition, the study
will examine to the extent that participants demonstrate commitment to integrate aspects of
Chinese culture and Mandarin language in the school curriculum. Furthermore, the study will
examine the extent that participation in this language and culture immersion project impacted the
participants’ cognitive growth in relation to other socio-cultural and linguistic factors such as:
their language proficiency level and background (number of languages spoken) at both preparticipation and post traveling abroad; educational background and experiences; prior years of
exposure to Mandarin language and Chinese culture; and age of acquisition.
All information gathered will be unidentified, subject’s names will be removed from data,
and the information gathered will be kept strictly confidential. Your school, school district
personnel, and professors will NOT have access to this information.
* I will be interested in receiving more information about possible participation in the Small
Scale Research Study included in this project: Yes__________ No__________
Thank you!
* Must provide an answers if applicable.
H. Availability for an interview
Preferred Day
__________ Monday ________ Tuesday ________Wednesday ________Thursday
AM - 9:00 am to 12:00 noon. Specify day and time: _________________________________
PM - 1:00 pm to 4:00 pm. Specify day and time: ____________________________________
Evening - 5:00 pm to 7:00 pm. Specify day and time: ________________________________
RETURN to: Fulbright-Hays Language and Culture Immersion Program
University at Buffalo
Graduate School of Education
Department of Learning and Instruction
Foreign/Second Language and Bilingual Education Programs
556 Baldy Hall
Buffalo, New York 14260
OR: E-mail malave@buffalo.edu