Student Name: __________________________       Grade:_____________________

School:______________________________        

Instructions for schools in completing the survey:

1. Interview the parents or guardians of ALL new kindergarten and incoming students in grades K-12 and record all information requested.
2. Provide interpretation services whenever necessary.
3. Check to see that all questions on the form are answered.

Complete this home language survey at the student’s initial enrollment in school. This form must be signed and dated by the parent or guardian. It must be kept in the student’s file. This form will be used only for determining whether the student needs English Learner services and will not be used for immigration matters or reported to immigration authorities. If the student’s first language was NOT English this form should be sent to Linda Dalton or Michelle Martin at Central Office

1. What is the primary language used in the home, regardless of the language spoken by the student? ___________________________ (specify language)
2. What is the language most often spoken by the student?___________________________ (specify language)
3. What is the language that the student first acquired? ___________________________ (specify language)
4. In which language do you prefer to receive information from the school? ___________________________ (specify language)
5. Have you moved in order to obtain agriculture work in the past 36 months? _____Yes   _____No
6. Is the student:  _____Migrant _____Immigrant     _____Refugee

Parent/Guardian Signature ________________________________________

Relationship to Student ________________________________ Date ________________________