6141.311 Form 1 6141.311 Form 1Programs For Limited English Proficiency Students
(Student Home Language Survey)
Student s Name: _______________________/___________________/___________________
First Middle Last
Date: _______________ School: ____________________
Person Completing Survey: _____ Mother _____ Father _____ Student _____ Guardian
_____ Other (specify): _______________________________
Circle the best answer to each question and provide additional information:
1. Was the first language you learned English? No Yes
2. Can you speak a language other than English? No Yes
3. Is any language other than English used at home? No Yes
4. Which language do you use most often with friends? English Other ______
5. Which language do you use most often with parents? English Other ______
6. Which language do you use most often with other relatives? English Other ______
7. Have you attended school in a country other than the United States? No Yes*
* If yes, how long and what grades?
8. Have you attended another school in the United States? No Yes*
* If yes, where and how long?
9. Have you attended another school in Connecticut? No Yes*
* If yes, where and how long?
10. Please provide any related information that would help the school (for example, referral to gifted or special education programs in prior schools, etc):
____________________________________________________________________________________________
____________________________________________________________________________________________
Note to school staff: This form should be given to all new and enrolling students. Any student that indicates the use of a language other than English should be assessed as to English proficiency. Elaboration on any of the above answers may be useful before administering detailed tests.
Adapted from the Assessment of Language Minority Students: A Handbook for Educators. Illinois Resource Center, 1985 Reprinted by permission of the Missouri Department of Elementary and Secondary Education.