ICEO - WAT Final Evaluation

Monthly Activity Report

Participant Information

Social Security#

- -

Last Name:

First Name:

Middle Initial:

DS-2019 #:

Date of Birth (mm/dd/yyyy):

U.S. Address :

(do not enter the address of your employer)

City:

State:

Zip:

Participant's phone number:

Employer Information

Employer:

Employer Address:

City:

State:

Zip:

Supervisor's Name:

Supervisor's Phone:
(555-555-5555)

- -

Employment

Start date of employment in the US (mm/dd/yyyy)

Month for report:

1 2 3

Please rate the following, thus far in your program, on a scale of 1-4 (1 - poor, 2 - average, 3 - good, 4 - excellent and 5 - not applicable)

Your cooperation with your employer:

1 2 3 4 5

Your Employment location:

1 2 3 4 5

Your job:

1 2 3 4 5

Your relationship with other ICEO participants:

1 2 3 4 5

Approximately, how many hours per week did you work last month?

hrs

Are you satisfied with your job?

YES NO

What is your current position?

If you aren’t satisfied with your job, what would you change about it?

Please list the cultural activities you have participated in during this month

Comments:

By clicking here, I confirm I am the person above and have completed this form to the best of my ability.




	WAT Program Definition

	Social Security & Taxes

	Eligible and Ineligible Jobs

	Travel Options



	ICEO WAT:

	Jobs

	Dates and Deadlines

	Orientation

	Insurance

	Housing

	Emergency Contact

	Download Forms

	Program Extensions

	Monthly Activity Report

	Final Evaluation


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