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FOR STAFF COMPLETION
TO BE COMPLETED FOR ALL NEW STUDENTS
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Today’s Date
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School Building
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_____
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PARENT/GUARDIAN HOME LANGUAGE SURVEY
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Student’s Name
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Grade
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Relationship of Person Completing Survey
Mother Father Guardian Other Specify_____
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Directions: Check the correct response for each of the following questions and indicate other languages if appropriate
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English
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Other
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Other Language(s)
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1. Place of Birth:_________________________
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2,What language was the child first exposed to?
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3.What language did the child learn when she or he first began to talk?
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_____
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4.What language does the family speak at home most of the time?
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_____
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5.What language does the child speak to her/his friends most of the time??
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_____
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Yes
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No
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6.Can an adult family member or extended family member speak English?
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_____
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7.Can the parent / guardian read English?
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_____
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8.Do the parents /guardians request communication in a language other than English?
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What language?___________________
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9.Number of years attending school in a country outside the US?
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_____
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10.Number of years attending school within the US?
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_____
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_____
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SIGNATURE
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Signature of Person Completing Survey
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Date Signed
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