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ANSWER SHEET
(Please print clearly)
Name:
___________________________________________________________________________
Last
First
Middle
Address: ___________________________________________________________________________
Street / Postal Box
___________________________________________________________________________
City
Date of Birth:
State/Province
Zip/Postal code
_______/_______/_________
Day
Month
Country
Year
Yes
________________________
No
Active
Inactive
NAME:_____________________________
Instructions: Circle the number that best describes how you act. There are no right or wrong answers, only answers that describe you.
Instructions: First transfer the number selected by the candidate for each item to the corresponding box in the
appropriate Scale. Total each Scale. Using the Total for each Scale, refer to the listing below to interpret the
score. Candidates may not be accepted when a candidate demonstrates two possible problem areas, i.e. two or
more scales meet the criteria for rejecting the candidate.
Scale A:
Item #
1
9
17
25
33
Total
Score
Scale B:
Item #
2
10
18
26
34
Total
Score
Scale C:
Item #
4
8
12
20
28
Total
Score
Scale D:
Item #
5
13
21
29
36
42
48
Total
Score
A total of 21 or 22 indicates a
Possible problem. A total score of
23 or more meets the criteria for
rejecting the candidate.
Scale E:
Item #
6
14
22
30
37
43
49
53
56
Total
Score
Score
Scale H:
Item #
40
46
47
Total
Score
Scale F:
Item #
7
15
23
31
38
44
50
52
54
55
58
Total
Scale G:
Item #
8
16
24
32
39
45
51
Total
Score
Scale I:
Item #
57
59
60
61
62
63
64
65
Total
Score
STRUCTURED INTERVIEW
(Please print clearly)
It is necessary that each au pair applicant be interviewed. The interview must be conducted exclusively in
English. Applicant responses and interviewer impressions should be recorded by the interviewer on this
form.
_______________________________________________
_________________________________
Applicant Name
Nationality
____________________________
Applicant Birth date
___________
Age
_________________________________
Interview Date
_______________________________________________
_________________________________
Interviewers Name
1.
2.
Has the applicant spent any time away from home (other than holidays), family and
friends?
Yes
No
If yes, where? ____________________________________________________________________
How much time? __________________________________________________________________
And, for how long? ________________________________________________________________
3.
Yes
No
5.
Ask the applicant to describe her/his family and the relationships between its members.
(Are both parents alive and currently living together? Are siblings at home, or have they moved
away? Is the family close and loving? What is the frequency of family member contact?)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
6.
Has the applicant discussed with her/his family her/his decision to spend a year abroad?
Yes
No Does the entire family support the applicants decision to spend a year in the
U.S.A. as an au pair?
Yes
No
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
7.
Excellent
Very Good
Good
Fair
Poor
Father:
Excellent
Very Good
Good
Fair
Poor
Siblings:
Excellent
Very Good
Good
Fair
Poor
Excellent
Very Good
Good
Fair
Poor
Other:
8.
___________
Yes
No
If yes, how would the applicant deal with being placed in a family where a church/temple of her/his
religious denominations is not easily accessible?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Give an example of the applicants tolerance of religious beliefs or practices other than her/his own.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
9.
What does the applicant expect or envision her/his American family might be like? (two-parent
family, one parent, both work, one works, city apartment, suburban house, cars, friendly, busy, rich,
etc) _____________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
10.
Does the applicant consider her/himself flexible and able to adjust to the lifestyle and culture of a
new family?
Yes
No
What qualities and characteristics does the candidate consider
important to the adjustment process?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
11.
How does the applicant feel about living with a family with very different political or philosophical
beliefs?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
12.
How does the applicant spend her/his free days now? (reading, jogging, swimming, studying, etc)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
13.
How does the applicant spend her/his free nights? (films, reading, discos, coffee shops, T.V., etc)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
14.
Many
Few
Yes
If yes, does the applicant feel she/he can live without this person for an entire year?
Has the applicant discussed with this person her/his decision to spend a year abroad?
No
Yes
Yes
No
No
If yes, how does her/his boy/girlfriend feel about spending 12 months without her/him, or if no
(havent discussed), why not?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
16.
What does the applicant plan to do upon her/his return from her/his au pair year in the USA? (job,
school, training, family, travel, etc)?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
17. Does the applicant plan to marry and/or have children of her/his own?
Yes
No
If yes, what is her/his idea of the timing (of marriage, home, children) and her/his concept of what
her/his family lifestyle would be (close-knit, active, outdoors, city, travel, farm)?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
18.
Does the applicant understand that she/he will be the primary care provider for the host familys
children for up to 45 hours each week?
Yes
No
Have the applicant describe the
characteristics and skills she/he considers to be the most important in successfully undertaking this
responsibility.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What problems or challenges does the applicant expect to encounter?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
19.
20.
Does the applicant have any other information that she/he feels is important or useful for the program
to know in placing her/him with a host family and its children?
Yes
No
If yes, please explain.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Dear Partners:
It is vital that all Au Pair applicants are aware of the challenges of living overseas and providing live-in
childcare. To ensure that they are aware of these challenges and that they are able to deal with these
challenges as they arise, we have listed some of the issues below. Please present the Au Pair with these
situations and ask him/her how she/he would deal with the situation:
1) Culture Shock
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2) Homesickness___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________