Colorado Springs School District 11
Has student ever been retained? *

Home Language Survey

3. Did your student ever receive English as a Second Language instruction? *
4. Is a language other than English spoken at home by a parent, sibling, or this child? *
If YES, please complete questions 5 - 7. If NO, proceed to the next section.
6. Who in the home communicates in this language? (Please respond to each statement)
a. This child *
b. Mother/Guardian *
c. Father/Guardian *
7. Does your child understand and speak English fluently? *
8. Did your child experience any problems or difficulties in learning to speak, read or write in his/her first language?