Home Language Survey

Student Name *

First

Last

Graduation Year *

Purpose

The Illinois State Board of Education requires all school districts to identify students who may be eligible for English language support services. This survey helps Holy Trinity High School determine whether a student should be assessed for English language proficiency.

Please answer the following questions by checking the appropriate response.

1. Is a language other than English spoken in your home?

If YES, which language(s)?

2. Does your student speak a language other than English?

If YES, which language(s)?

3. Does your student understand a language other than English?

student Year Time

If YES, which language(s)?

Parent/Guardian Certification

I certify that the information provided on this survey is accurate to the best of my knowledge.

Parent/Guardian Name

First

Last

Date / Time

Date

Time

Home Language Survey

Home Language Survey

Purpose

Parent/Guardian Certification

Holy Trinity High School

Location