Home Language Survey

Dear Parents and Guardians:

Required by state, a mandatory Home Language Survey must be given
by public schools in Pennsylvania. This helps our school district identify
students who are in need of being assessed for English language
proficiency.
Do you need a translator?: Yes No
If yes, what language?: ________________________________________________
School District:
_________________________________________________________
School: ________________________________________________________________
Students Name:
_______________________________________________________
Students Date of Birth: ________________________
Fathers Name: ________________________________________________________
Mothers Name: _______________________________________________________
Address:
_______________________________________________________________

_______________________________________________________________
Phone number: ________________________________________________________
Please complete the following questions. If the answer is English to the
first three, you do not need to complete the form. If the answer is
another language other than English, please complete the entire form.

1. What is/was the childs first language?

_____________________________
2. Does the child speak a language other than English?
Yes No
3. What language is spoken in your household?
_____________________________
4. What is the childs birth country?
_____________________________
5. Can the child read in English? Yes No
6. Can the child write in English? Yes No
7. What is the date of entry into the United States?
__________________

*Parent/Guardian signature:
_________________________________________

Thank you for completing the survey.