6:160-E1 Student Home Language Survey

This form must be completed for each student entering the District for the first time. Students who indicate the use of a language other than English may be assessed as to English proficiency. Answers to this survey are useful in determining whether to administer further tests.

Dear Parent/Guardian,

The Federal NCLB-Title III Act and the Illinois School Code require that each school district administer a Home Language Survey to every student entering the district’s schools for the first time. This information is used to report to the state the number of students whose families speak a language other than English. It also helps to identify the need for English Language Learning services in the schools. Your cooperation in helping us meet this important legal requirement is appreciated. Student Name_____________________________________________ Grade___________ School__________________________ Birthdate____________ Gender_______

Country of Birth _____________  Home Phone Number_______________________

1. Is a language other than English spoken in the home? YES NO

If yes, what language? ______________________

2. Does the student speak a language other than English? YES NO

If yes, what language? ________________________________

_________________________________________        ___________

Parent/Guardian Signature                                               Date

****If you answered NO to both questions #1 and #2, you may STOP here. *******If you answered YES to either question, please go on to #3.

3. Which language is spoken most often in your home? _________________________________

Please be specific. (example: Mandarin, not Chinese)

4. About the language, other than English, that the student speaks,

… can the student read this language? YES NO

… can the student write this language? YES NO

… has the student ever received instruction in this language? YES NO

If yes, what grade(s)? _____________ Where? ________________________

5. Does this student ……

…understand English? YES NO … speak English? YES NO

…read English?            YES NO … write in English? YES NO

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

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

8. Where did this student attend school last year? ______________________________________________

9. Did this student ever receive extra help to learn English?      YES NO

10. If you speak a language other than English, would you be willing to occasionally translate at school if needed?        YES NO

Approved: April 10, 2007