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Colorado Springs School District 11

Student Last Name *

First Name *

School *

Grade *

Has student ever been retained? *

Yes

No

If yes, what grade? *

Home Language Survey

1. What language(s) did your child use when he/she first began to talk? *

2. What language(s) does your child speak with you at home? *

3. Did your student ever receive English as a Second Language instruction? *

Yes

No

4. Is a language other than English spoken at home by a parent, sibling, or this child? *

Yes

No

If YES, please complete questions 5 - 7. If NO, proceed to the next section.

5. What is the language?

6. Who in the home communicates in this language? (Please respond to each statement)

a. This child *

Always

Usually

Seldom

Never

b. Mother/Guardian *

Always

Usually

Seldom

Never

c. Father/Guardian *

Always

Usually

Seldom

Never

7. Does your child understand and speak English fluently? *

Yes

No

8. Did your child experience any problems or difficulties in learning to speak, read or write in his/her first language?

Yes

No

If yes, please explain