Home Language Survey
This form must be completed for every student to determine who speaks a language other than English or who comes from a home where a language other than English is spoken. In answering these questions do not include students or parents who have learned a foreign language by taking classes or by other similar means.
Student First Name
Your answer
Student Last Name
Your answer
Birthdate
MM
/
DD
/
YYYY
Grade
Parent's Names:
Your answer
Student's Country of Birth
Your answer
1. Is a language other than English used in the home?
If yes--What Language?
Your answer
2. Was the Student's first language English?
If no--What language did the student first learn to speak?
Your answer
3. Does the student speak a language other than English?
If yes--What Language?
Your answer
4. Primary language spoken by Student
Your answer
5. Primary language spoken by Father
Your answer
6. Primary language spoken by Mother
Your answer
Official Digital Signature
I understand that if my child first spoke a language other than English, or if another language other than English is spoken in the home, my child's English language proficiency will be evaluated. Since this information is being gathered online rather than through traditional paper and pencil methods, a digital signature is required. My initials, as typed below represent my signature .
Your answer
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