Home Language Survey

 

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

9.Number of years attending school in a country outside the US?
_____
10.Number of years attending school within the US?
_____
_____
SIGNATURE
Signature of Person Completing Survey

 

Date Signed