Home Language Survey

Year *
PARENT/GUARDIANS: PLEASE RETURN THIS COMPLETED FORM TO YOUR CHILD'S SCHOOL
(The original is to be given to the CORE ESOL teacher in your building OR sent to USD383's ESOL Coordinator
The US Department of Education requires that USD383 determine the number of children attending school who live in homes where a language other than English is spoken. Federal law also requires that USD383 test the English proficiency of all children who live in homes where a language other than English is spoken within 30 days of their enrollment The information on this survey also provides the basis for Federal Title III funding for the school district that provide testing, English language education for PK-12 students, curriculum materials and ESOL professional development for USD383 teachers and staff. The information on this form will not be released without your written approval.
Name of child *
Date of Birth *

Month Day Year
Date
Gender *

Male Female
School *
Grade
#1. Does anyone in the home speak a language other than English? *

YES NO
STOP HERE, if the answer to question #1 is NO.

Please provide signature and date at the bottom of the page
Mother's languages?
Dialect
Father's languages?
Dialect
In what country was your child born?
What date did your child enter the U.S. (if not born in the U.S.)

Month Day Year
Date
What date did your child first enroll in a U.S. school?

Month Day Year
Date
City
State
What date did your child first enroll in a Kansas School?

Month Day Year
Date
City
What date did your child first enroll in Manhattan Ogden USD 383?

Month Day Year
Date
Grade:
School:
Has your child ever qualified for an English Language Development (ESOL, ESL, ELL, ELD) program?

YES NO
Grade
School
What language did your child learn to speak/use first?
What language does your child most often speak/use at home?
What language do you most often speak/use with your child?
What language do the adults regularly present or living in the home most often speak/use while in the presence of the child?
Does your child's mother understand and/or speak English?
Does your child's mother understand English?

Yes No
Does your child's mother read English?

Yes No
Does your child's father understand English?

Yes No
Does your child's father read English?

Yes No
What is your preferred contact language? To the extent practicable, communication from the school will be provided in this language.
Please specify "written" or "spoken".
Home / Cell Phone *
Work Phone *
Would you be willing to serve as an interpreter to assist other families? *

YES NO
Date *

Month Day Year
Date
Should be Empty:

PARENT/GUARDIANS: PLEASE RETURN THIS COMPLETED FORM TO YOUR CHILD'S SCHOOL