Student 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:
Country of Birth: Date of Birth: (mm/dd/yyyy) Gender: F M
Initial enrollment date at ANY US school (mm/dd/yyyy)
School Information
Start Date in New School : (mm/dd/yyyy) Name of Former School and Town:
Grade:
Questions for Parents/Guardians
What is the primary language used in the home, regardless of the
language spoken by the student?
1. _____________ mother father Guardian
2. _____________ mother father Guardian
Which language(s) are spoken with your child?
(include relatives - grandparents, uncles, aunts,etc. - and caregivers)
1. _____________ Seldom sometimes often always
2. _____________ Seldom sometimes often always
What language did your child first understand and speak?
1._____________
Which language do you use most with your child?
1. _____________
How many years has the student been in U.S. Schools? (not
including pre-kindergarten)
________________________________________________
Which languages does your child use?
1. _____________ Seldom sometimes often always
2 _____________ Seldom sometimes often always
Will you require written information from school in your native
language? Yes No
If yes, what language? ______________________
Will you require an interpreter/translator at Parent-Teacher meetings?
Yes No
If yes, what language? ________________________________
Parent/Guardian Signature:
X
Today’s Date: (mm/dd/yyyy)
08/31/20
Estimated Start Date