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Parent/Guardian Home Language Identification Survey
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* Indicates required question
1-Student Last Name
*
Your answer
2-Student First Name
*
Your answer
3-What language(s) does the child understand?
*
English
Other:
Required
4-What language(s) does the child speak?
*
English
Other:
5-What language(s) does the child read?
*
English
Does not read
Other:
Required
6-What language(s) does the child write?
*
English
Does not write
Other:
Required
7-What language is spoken in the child's home or residence most of the time?
*
English
Other:
Required
8-What language does the child speak with parents/guardians most of the time?
*
English
Other:
Required
9-What language does the child speak with brothers, sisters, or friends most of the time?
*
English
Other:
Required
10-What language does the child speak with other relatives or caregivers (e.g., babysitters) most of the time?
*
English
Other:
Required
11-Is this the first time the child has attended a school in the United States?
*
Yes
No
12-If the child has attended a school in the U.S. before, name the school.
Your answer
13-How many hours did the child attend school each day?
Your answer
14-Which language was used for instruction at the school the child attended?
Your answer
15-Has there ever been a time when your child missed school for an extended time? Why?
Your answer
16-Has the child attended a school in another country?
Yes
No
Clear selection
17-If your child attended school in another country, name the country.
Your answer
18-How long did he/she attend school in that country?
Your answer
19-Which language was used for instruction in that country?
Your answer
20-Did the child participate in any group experience prior to entering school (e.g. daycare, pre-school)?
Yes
No
Clear selection
21-If YES, what language was used during the group experience?
Your answer
22-Does the child use any other form(s) of communication, such as American Sign Language or Augmentative Communication Device (e.g., communication board-manual/electronic)?
Yes- American Sign Language
Yes- Augmentative Communication Device
No
Other:
23-In what language would you like to receive written information from the school?
*
Your answer
24-In what language would you prefer to communicate orally with school staff?
*
Your answer
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This form was created inside of P.S. 201 Q, The Discovery School for Inquiry and Research.
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