Home Language Survey

Student Name*

Grade*

Name of School*

Birthdate*

Gender*

Country of Birth*

1. Does anyone in your home speak a language other than English?*

Yes
No

What language is spoken at home?

2. Which language is spoken most often in your home? (Please be specific, example: Mandarin, Not Chinese)

3a. Does this student speak a language other than English?

Yes
No

Note: Foreign languages the student has learned in school does not count. If the answer is NO, go to question #7. If the answer is YES, please continue.

3b. What language, other than English, does this student speak?

3c. Can the student read this language?

4a. Does the student understand English?

Yes
No

4b. Does the student speak English?

Yes
No

4c. Does the student read English?

Yes
No

4d. Does the student write English?

Yes
No

5. What language does this student speak most often with his/her parents?

6. Which language does this student speak most often with his/her friends?

7. Where did this student attend school last year?

8. Was this student in a bilingual or ELL/ESL program during the last school year?

Yes
No

8a. What grade(s)?

8b. Where (school/city)?

Date

Parent Signature*

(by signing/typing your name, you understand and agree with all of the information that is in this form)

Home Language Survey

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