FORM
Home Language Survey
2
This form does NOT determine eligibility or testing for the CPS Spanish, Chinese, or
Portuguese Language Immersion Programs. This form is required by the MA Department of
Elementary and Secondary Education (DESE) to identify students who need assistance learning English as a second
language. If a language other than English is listed, the District is required to assess your
child in English Proficiency in order to identify their English language learning needs. This
information is essential in order for schools to provide meaningful instruction for all students.
Student Information
First Name
Middle Name
Country of Birth
/
/
Date of Birth (mm/dd/yyyy)
F
Gender
Last Name
M
/
/
Date first enrolled in ANY U.S. school (mm/dd/yyyy)
School Information
/
/20
______
Start Date in New School (mm/dd/yyyy)
Name of Former School and Town
Current Grade
Questions for Parents/Guardians
1. What is the native language(s) of each parent/guardian? (circle one)
2. Which language(s) are spoken with your child?
(include relatives -grandparents, uncles, aunts,etc. - and caregivers)
(mother / father / guardian)
seldom / sometimes / often / always
(mother / father / guardian)
3. What language did your child first understand and speak?
seldom / sometimes / often / always
4. Which language do you use most with your child?
5. Which other languages does your child know? (circle all that apply)
6. Which languages does your child use? (circle one)
speak / read / write
speak / read / write
7. Will you require written information from school in your native
language?
Y
N
Parent/Guardian Signature:
seldom / sometimes / often / always
seldom / sometimes / often / always
8. Will you require an interpreter/translator at Parent-Teacher meetings?
Y
N
/
Today’s Date:
X
/20
(mm/dd/yyyy)
Do you need this document translated? If yes, in what language__________________________
Arabic
Chinese (Traditional)
Haitian Creole
Spanish
Portuguese
French
Bengali
Gujarati
□ ‫عم‬
‫ن‬
‫ال ت ح تاج هذه ال وث ي قة ال م ترجمة؟‬
你需要這份文件翻譯？
□ 是的
Ou bezwen dokiman sa a tradui?
□ wi
¿Es necesario este documento traducido?
□ Sí
Você precisa deste documento traduzido?
□ Sim
Avez-vous besoin de ce document traduit?
□ oui
এই
?
□
આ
?
□
For Internal Office Use Only:
1)0 ; 2)1 ; 3)1.5 ; 4)1 ; 5)1 ; 6)1 ; 7)0 ; 8)0
1 to 2 = No Testing
2.5 to 5.5 = English Proficiency Test Required; Please Schedule Test
Total_________________