Home Language Survey
The state requires the district to collect a Home Language Survey for every new
student. This information is used to count the students whose families speak a language
other than English at home. It also helps to identify the students who need to be
assessed for English language proficiency.
Please answer the questions below and return this survey to your child’s school.
Student’s Name: ______________________________
1. Is a language other than English spoken in your home?
Yes _____ No _____
What language? ________________________
2. Does your child speak a language other than English?
Yes _____ No _____
What language? ________________________
If the answer to either question is yes, the law requires the school to assess your
child’s English language proficiency.
________________________________ _____________________________
Parent/Legal Guardian Signature Date
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