LANGUAGE BACKGROUND QUESTIONNAIRE

Name of Student :
Grade/Year :

Part 1. These questions are given to collect the information when you were 0-5 years old

Birth Date (Day, Month, Year) Place of Birth

Tanggal Lahir (Tanggal, Bulan, Tahun) Tempat Lahir

Where did you live?

Dimana anda tinggal?

Language Spoken with

Bahasa yang digunakan saat bersama
Mother Father
Ibu Ayah

Mother and Father together Siblings

Ibu dan Ayah Saudara kandung

Others
Anggota keluarga lain

What was your primary language 'in play' or with friends?

Apa bahasa yang anda gunakan saat bermain/saat bersama teman-teman?

*adapted from the Language Background Questionnaire by Westminster

International School

Part 1. These questions are given to collect the information when you are in the past 5 year

Where do you live?

Dimana anda tinggal?
 Language Spoken with
Bahasa yang digunakan saat bersama
Mother Father
Ibu Ayah

Mother and Father together Siblings

Ibu dan Ayah Saudara kandung

Others
Anggota keluarga lain

What is your primary language 'in communicate' or with friends?

Apa bahasa yang anda gunakan saat berkomunikasi/saat bersama teman-teman?

*adapted from the Language Background Questionnaire by Westminster

International School