Demo Southwest Plains

Demo

Home Language Survey

Upon enrollment, every student or parent/guardian must be given a Home Language Survey. This survey will be used to determine which students should be assessed for English proficiency. Knowledge of, or exposure to another language does not, in and of itself, qualify a student for ESOL services. If a language other than English is indicated in any of questions 1-4, the student will be assessed to determine eligibility for English for Speakers of Other Languages (ESOL) services. The assessments approved by Kansas State Department of Education include: The Language Assessment Scales (LAS)/LAS LINKS/Pre-LAS, the IDEA Proficiency Test (IPT)/Pre-IPT, the Language Proficiency Test Series (LPTS), and the Kansas English Language Proficiency Assessment (KELPA)/KELPA-P. If a student scores below proficient/fluent in any of the language domains: listening, speaking, reading, or writing, s/he is eligible for ESOL services. Please complete one form for each child.

Student Information

District:
First Name: Last Name:	Grade:
Address:	Date of Birth:
Date first enrolled in a school in the U.S.:	Phone Number:

Student Language Information:

1. What language did your child first learn to speak/use?
English
Spanish
Other (please specify)

2. What language does your child speak/use at home? Do not include language learned in a class or through television or other such programming.
English
Spanish
Other (please specify)

3. What language do you speak/use with your child?
English
Spanish
Other (please specify)

4. What language do the adults regularly present or living in the home speak/use while in presence of the child?
English
Spanish
Other (please specify)

Parent/Guardian Information:
Which language do you prefer?
English
Spanish
Other (please specify)

(Please specify “written” or “spoken”. To the extent practicable, communication from the school will be provided in this language.)

Please help us determine your child’s eligibility for the Title I Part C of the Elementary and Secondary Education Act of 1965 (ESEA) by responding to the following questions.

Have you or a member of your family moved in the last 36 months to do, or apply for, agriculture or fishing related work, including dairies, nurseries, meat or vegetable processing, feed yards, or field work?
Yes
No

Have your children moved with or to join the worker above in the past 36 months?
Yes
No

Signature of Parent or Guardian (Please type in your full name)