The Wayback Machine - https://web.archive.org/all/20041014212342/http://speakout.state.gov/index.cfm?vals=personal&form=a
In Their Own Words
SURVEY NUMBER SV-2001-0013-A  |  OMB NUMBER 1405-0018  |   Estimated Completion Time 20 MINUTES
U.S. Department of State | Bureau of Educational and Cultural Affairs
If you prefer to make
your statement without
using the questionnaire
please email:
ecatestimonials@pd.state.gov

If you have any questions
please send email to:
speakout@state.gov

Submitting a comment about your experience.
Denotes required entries.
Last Name
First Name
Middle Initial
Institution Affiliation
Present Position
Email
Country of Origin
Exchange Program in which Participated
Exchange Program Year    yyyy
Country in Which Effort or Activity Took Place
Date When Effort or Activity Took Place (approximate)
mm/dd/yy
Start Date
 End Date
Topic / Theme
Brief description of the activity or effort


Instructions & Example
Brief explanation of how the activity or effort affected your view of the country you visited and contributed to mutual understanding and good will between the US and that country. You may also include how you have been able to influence other people's opinions upon your return home.

Instructions & Example
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