Home Language Survey Form

Home Language Survey Form

2021-22
Students Name *

First Name Last Name
Attending School District *
The State of Illinois requires each district to collect a Home Language Survey for every student. This information is used to count the students whose families speak a language other than English at home. It also helps to identify the students who need to be assessed for English language proficiency and may need additional services at school.

Please answer the questons below.
Is a language other than English spoken in your home? *

Yes No
If yes, what language:
What language is spoken in your home
Dose your child speak a language other than English? *

Yes No
If yes, what language:
What language is spoken in your home
If the answer to either question is yes, the law requires the school to assess your child’s English language proficiency. This will be done in the preschool classroom using the Pre-IPT Oral English Language Proficiency. Results will be shared with you.
Signature

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Date

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Date
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