6141.311 Appendix A

Recommended Home Language Survey (HLS)

DISTRICT NAME

Welcome to our school!

To assist the district in ensuring we provide your child with appropriate programming, we have a few questions about languages spoken at home. The language information also helps us know how we can best communicate with you. Please share with us about the language(s) spoken by your family and in your home. (Please find the Parent Bill of Rights for English Learners/Multilanguage Learners on the District website.)

___________________________________________________________________________________

___________________________________________________________________________________

Student Information

Student first name: ________________________ Student last name: ______________________

Date of birth: _________________________

1)  What is the primary language used in the home, regardless of the language spoken by the student?

________________________________________________________________

2)  What is the language most often spoken by the student? ___________________________

3)  What is the language the student first acquired? __________________________________

Optional questions that can be included:

1)   What language do you prefer for written communication from the school?

________________________________________________________________________

2)   Will you require interpretation/translation at Parent-Teacher meetings?

________________________________________________________________________

_____________________________
Parent/guardian name (please print)

_____________________________                         ________________________
Parent/guardian signature                                              Date

Thank you for answering the questions. We look forward to working with your child. 

(Recommended HLS Guidance prepared for CT SDE by Home Language Survey Working Group, December 2015 (facilitated by REL Northeast and Islands.)