Cleveland City School System

K-6

Home Language Survey Form

Name of Student_________________________________ Grade________________

School_________________________________________ Date_______________________

        1.  What was the first language you learned to speak?

                _________________________________________________________

        2.  What language do you speak most often?

                __________________________________________________________

        3.  What language is spoken most often in your home?

                ___________________________________________________________

        4.  Can an adult in the home speak English?   Yes_______  No___________

              If the answer is no, what language can be read? ________________________

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Instructions to the Principals:  The above questions must be presented verbally and individually to each student unless you are absolutely sure that the student is capable of reading, understanding, and writing responses to each question accurately and independently.  The response to each question must be recorded on this form.  One form must be completed for each student.  If the answer to all four questions is "English," place the completed form in the student's cumulative folder.  If the answer to any question is a language other than English, FAX the form to the ESL Supervisor with a copy of the student's registration data form before placing in the cumulative folder.  Check one of the statements below, sign, and date.  Thank you for your assistance.

The questions were presented verbally; responses were recorded by the administrator/designee.  ________

These questions were presented verbally and responses were recorded by the student.  _______

These questions were presented in writing and responses were recorded by the student.  _______

 _____________________________

 Signature of Administrator or Designee

  __________________

Date