Editing previous response:

Please fix the highlighted areas below before submitting.

Home Language Survey

Please complete the form below. Required fields marked with an asterisk *

The Civil Rights Law of 1964, Title VI, requires that school districts/charter schools identify Limited English Proficient (LEP) students. Pennsylvania has selected the Home Language Survey as the method for the identification.

School District*

Answer required for "School District"

Date*

Answer required for "Date"

School*

Answer required for "School"

Students Name

First*

Answer required for "First"

Last*

Answer required for "Last"

Grade*

Answer required for "Grade"

What was the student’s first language?*

Answer required for "What was the student’s first language?"

Does the student speak a language other than English?

Answer required for "Does the student speak a language other than English?"

Yes

What language(s) is/are spoken in your home?*

Answer required for "What language(s) is/are spoken in your home?"

Parent/Guardian Name

First*

Answer required for " First"

Last*

Answer required for "Last"

Parent/Guardian signature*

Signature Required

*The school district/charter school has the responsibility under the federal law to serve students who are limited English proficient and need English instructional services. Given this responsibility, the school district/charter school has the right to ask for the information it needs to identify English Language Learners (ELLs). As part of the responsibility to locate and identify ELLs, the school district/charter school may conduct screenings or ask for related information about students who are already enrolled in the district as well as from students who enroll in the school district/charter school in the future.

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"