Home Language Survey



HOME LANGUAGE SURVEY ALL newly registering students regardless of race, nationality, or language origin MUST complete this form. Federal law requires that all Local Education Agencies (LEAs) utilize a non-biased procedure for identifying which students are potential English Learners (ELs) in order to provide appropriate language instruction educational programs and services. Given this responsibility, LEAs have the right to ask for the information contained on this and other forms associated with the identification process.Student Information (Parents/Guardians should complete this section):106680014438900Child’s first name: 12133381371600Child’s family name: 1213338125974Child’s Date of Birth: (Month/Day/Year)4506741306803040087553060700Questions for Parents or Guardians4102100287655045421552876550573258513584101. Is a language other than English spoken in the child’s home? No Yes (language)5732585105410002. Does your child communicate in a language other than English? No Yes (language)3839308104287003. What is the language that your child first learned to speak? 17456152705100127127026543005234353125779170570812577900Parent/Guardian Signature: Date:Interpreter Provided No Yes ................
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