English/November 2016
Office of Superintendent of Public Instruction (OSPI)
Home Language Survey
The Home Language Survey is given to all students enrolling in Washington schools.
Student Name:
Parent/Guardian Name Parent/Guardian Signature
Right to Translation and
Interpretation Services
Indicate your language preference so
we can provide an interpreter or
translated documents, free of
charge, when you need them.
All parents have the right to information about their child’s
education in a language they understand.
1. In what language(s) would your family prefer to communicate
with the school?
Eligibility for Language
Development Support
Information about the student’s
language helps us identify students
who qualify for support to develop
the language skills necessary for
success in school. Testing may be
necessary to determine if language
supports are needed.
2. What language did your child learn first?
3. What language does your child use the most at home?
4. What is the primary language used in the home, regardless of
the language spoken by your child?
5. Has your child received English language development support
in a previous school? Yes___ No___ Don’t Know___
Prior Education
Your responses about your child’s
birth country and previous
Give us information about the
knowledge and skills your child is
bringing to school.
May enable the school district to
receive additional federal funding
to provide support to your child.
This form is not used to identify
students’ immigration status.
6. In what country was your child born? ___________________
7. Has your child ever received formal education outside of the
United States? (Kindergarten 12
grade) ____Yes ____No
If yes: Number of months: ______________
Language of instruction: ______________
8. When did your child first attend a school in the United States?
(Kindergarten 12
Month Day Year
Thank you for providing the information needed on the Home Language Survey. Contact your school
district if you have further questions about this form or about services available at your child’s school.
Note to district: This form is available in multiple languages on http://www.k12.wa.us/MigrantBilingual/HomeLanguage.aspx. A response that
includes a language other than English to question #2 OR question #3 triggers English language proficiency placement testing. Responses to
questions #1 or #4 of a language other than English could prompt further conversation with the family to ensure that #2 and #3 were clearly
understood. ”Formal education” in #7 does not include refugee camps or other unaccredited educational programs for children.
Forms and Translated Material from the Bilingual Education Office of the Office of Superintendent of Public Instruction are licensed under a Creative
Commons Attribution 4.0 International License.
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