Registrar’s Office
HOME LANGUAGE SURVEY (PK-12) 2023-2024 Student Information Last Name
First Name
Middle Name
PEIMS #
Gender
Date of Birth
Grade
Student’s Home Address Apartment #
Street Number
State
Street Name Zip Code
City Home Phone Number
Cell Phone Number
Alternate Phone Number
Home Language Survey
Specify Language
1. What language is spoken in your home most of the time? * 2. What language does your child speak most of the time? (PK – 8th Grade) * What language does your child (Do You) speak most of the time? (9 th – 12th Grade) * 3. Country of birth? 4. Has your child lived outside the U.S. for two (2) or more consecutive years (since birth)? Yes, my child attended regularly in all previous grades outside the U.S. 5. When your child lived outside the U.S., did he No, my child missed significant portions of one or more school years. or she attend school regularly? (Check One)
6. Please complete the following chart as accurately as possible. [If available, please provide the most recent report card for your child’s last school.] Grade
Attended U.S. School [√]
Complete Year (C), Partial Year (P), No Schooling (N/S)
Attended School Outside the US [√]
Complete Year (C), Partial Year (P), No Schooling (N/S)
If not U.S., What City, State, Country
PK KG 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
PREKINDERGARTEN eligibility, a child must be four years of age on September 1st of the current school year and must be: 1. unable to speak and comprehend the English language; or educationally disadvantaged (eligible to participate in the National Free or Reduced-Price Lunch Program); or 2. homeless, as defined by 42 U.S.C. Section 11302, or 3. the child of an active duty member of the US armed forces or 4. the child of a member of the US armed forces, who was injured or killed while serving on active duty; or 5. has ever been in the conservatorship (foster care) PRIOR EDUCATIONAL KNOWLEDGE: Did your child attend Head Start, Day Care, or other? Yes/No If yes, (where) How many years did he/she attend?
FOR OFFICE USE ONLY NOTES TO SCHOOL PERSONNEL: * An answer of a language other than English to either or both questions will require oral language proficiency assessment. OLPT Score _/_________ For Language Codes refer to Table ID C092
CODE
I certify that the above information is true and correct to the best of my knowledge.
SIGNATURE: ________________________________________Date:______________________ GRADES PK-8th PARENT OR GUARDIANGRADES 9th – 12th: PARENT, GUARDIAN OR STUDENT
(LANGUAGE CODE)
• RECENT IMMIGRANT CODE 1 : Table E0797 Yes
No
(in accordance with Title III & Chapter 89)
Form HLS E Rev 16/17