Home Language Survey



Student Information

First Name:

Last Name

Date of Birth


__female __male

Country of Birth

Date of entry in US

Date first enrolled in a US School

Month year

Current grade

Family Information

Name of parent/legal guardian

Phone number


__ Please translate school notices


Questions for Parent/Guardian


Please list all languages spoken in your home

Which language did your child first hear or speak?

If English is the only language listed, stop here. If another language is listed, please answer the rest of the questions.

Which language(s) do you speak to your child?

Which language(s) does your child speak at home with adults?

Which language(s) does your child speak at home with other children?

Number of years of school outside the U.S.

For parents and guardians :   If a language other than English is listed above, and ESOL teacher will test your child to find out if he or she can speak, understand, read and write well in English.   The results will be sent to you within 30 days.   Based on the results of the test, your child may be eligible to enroll in an English language (ESOL) class at school.   Parents/guardians may accept or decline ESOL program services for their child.

Instructions for survey administrator:
Please provide an interpreter when necessary.

If responses indicate a language other than English, please contact the ESOL teacher and provide her/him with a copy of this survey.  Date of referral to ESOL teacher:_____________

File original Home Language Survey in student's cumulative folder