Appendix B - Home Language Survey

  • Massachusetts Department of Elementary and Secondary Education regulations require that all schools determine the language(s) spoken in each student’s home in order to identify their specific language needs.  This information is essential in order for schools to provide meaningful instruction for all students.  If a language other than English is spoken in the home, the District is required to do further assessment of your child.  Please help us meet this important requirement by answering the following questions.  Thank you for your assistance.

    Student Information

    First Name _______________________________

    Middle Name _______________________________

    Last Name _______________________________

    Gender     F   M

    Country of Birth _______________________________

    Date of Birth (mm/dd/yyyy)  _____­­­_ /______ /______

    Date first enrolled in ANY US school  _____­­­_ /______ /______ 

    School Information

    Start Date in New School  _____­­­_ /______ /______

    Name of Former School and Town _______________________________

    Current Grade __________

    Questions for Parents/Guardians

    What is the native language(s) of each parent/guardian? (circle one)

    ______________________ (mother / father / guardian)

    ______________________ (mother / father / guardian)

    Which language(s) are spoken with your child?
    (include relatives, grandparents, uncles, aunts, etc.)

    __________________  seldom/sometimes/often/always

    __________________  seldom/sometimes/often/always

    What language did your child first understand and speak?

    Which language do you use most with your child?

    Which other languages does your child know?(circle all that apply)

    ____________________________ speak / read / write

    ____________________________ speak / read / write

    Which languages does your child use? (circle one) 

    _____________________ seldom/ sometimes/ often/ always

    _____________________ seldom/ sometimes/ often/ always
    Will you require written information from school in a language other than English? ____ (YES)  ____ (NO)

    Will you require an interpreter/translator at Parent Teacher meetings? ____ (YES)  ____ (NO)

    Parent/Guardian Signature:


    Today’s Date:

    ______ / ______ / ______