Fillable North Carolina Home Language Survey Form (Camden County Schools)

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North Carolina Home Language Survey Form (Camden County Schools)

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North Carolina Home Language Survey Form
Directions:
1. Parents/guardians of all new students (including preschool and Kindergarten) complete this form at the
time of enrollment and record all information requested. Provide interpreting services whenever
necessary.
2. Ensure that all questions on the form are completed. Determine which ESL Program staff will review
the responses, interview the parent as necessary, and/or observe the student to determine the home
language. If the parent lists more than one language other than English, the reviewer must determine
which one is the child’s home language for data collection purposes and document it on this form.
3. If it is determined that a student’s home language is other than English, administer the English
language proficiency test. Follow your protocol to collect and document the student’s scores.
4. Place the original form in the student’s cumulative folder.
Student Information
First Name:
Last Name:
Country of Birth:
Date first enrolled in any U.S. school
(Private or Public, but not PreK) Indicate if
the student left the U.S. for a school year(s):
Date of Birth:
Current School:
School Enrollment Date:
Current Grade:
Questions for Parents/Guardians*
Parent Response
What is the first language the student learned to speak?
What language does the student speak most often?
What language is most often spoken in the home?
Notes:
*******************************For Office Use Only*****************************
Person Reviewing this Survey: ____________________________
Determination
The student’s home language
Language:
If the language is other than English, the English
language proficiency test should be administered
Administer the English Language
Proficiency Test
Check: Yes or No
Revised February 7, 2019
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North Carolina Home Language Survey Form (Camden County Schools)

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Completed 10 January 2021

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