English proficiency form

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Annex II



at Georgia State University

Federal regulations 22 C.F.R. § 62.10(a)(2) require prospective J-1 exchange visitors and participants of other programs to possess “sufficient proficiency in the English language to participate in his or her program.”
Instructions: If the required interview was conducted in English by the GSU host professor, this form may be completed by that same GSU host professor. Otherwise, this form must be completed by an English Instructor at an academic institution or by an English Language School (Section 2).
Alternatively, the host department may submit copies of the prospective exchange student’s TOEFL scores. TOEFL scores must be no more than two years old and show scores the meet the minimums listed in the specific exchange agreement. Current agreement template minimums are TOEFL CBT score of 250 and a score of 5 on the TOEFL essay or a minimum composite TOEFL iBT score of 80, with a Writing score of at least 22.

Name of Student:


English proficiency is documented by the following (Check at least one)
 Completed and signed by GSU host professor after completing interview in English.

 Completed and signed by an English teacher.

 Copy of TOEFL score is attached. Score must be no more than two years old and show the minimum scores required in the agreement.
I have interviewed this student on __________ (date) and can verify that s/he possesses sufficient proficiency in the English language to do the following:
dYes dNo Perform his/her J-1 activities or complete their academic programs;

dYes dNo Function on a day-to-day basis;

dYes dNo Read and comprehend program materials.

This interview was conducted (circle one): in person, video conference, telephone.

___________________________ ___________________________ _________________

Signature Name (printed) Date

___________________________ ___________________________ __________________

Title Name of Institution E-mail address

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