Home Language Survey
Surname/Family Name of Student:
First Given Name of Student:
Second Given Name of Student:
Age of Student: Grade Level of Student:
Teacher Name:
Directions to Parents and Guardians:
The California Education Code contains legal requirements which direct schools to assess the English
language proficiency of students. The process begins with determining the language(s) spoken in the
home of each student. The responses to the home language survey will assist in determining if a
student's proficiency in English should be tested. This information is essential in order for the school to
provide adequate instructional programs and services.
As parents or guardians, your cooperation is requested in complying with these requirements. Please
respond to each of the four questions listed below as accurately as possible. For each question, write
the name(s) of the language(s) that apply in the space provided. Please do not leave any question
unanswered. If an error is made completing this home language survey, you may request correction
before your student's English proficiency is assessed.
1. Which language did your child learn when they first began to talk?
2. Which language does your child most frequently speak at home?
3. Which language do you (the parents and guardians most frequently
use when speaking with your child?
4. Which language is most often spoken by adults in the home?
(parents, guardians, grandparents, or any other adults)
Please sign and date this form in the spaces provided below, then return this form to your child's
teacher. Thank you for your cooperation.
Signature of Parent or Guardian
Date
California Department of Education Form HLS, Revised July 2020
