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Home Language Survey (2024-25)

Surname/Family Name of Student*

Answer required for "Surname/Family Name of Student"

First Name of Student*

Answer required for "First Name of Student"

Middle Name of Student

Answer required for "Middle Name of Student"

Age of Student*

Answer required for "Age of Student"

Grade Level of Student*

Answer required for "Grade Level of Student"

Teacher's Name*

Answer required for "Teacher's Name"

Directions to Parents and Guardians:

The California Education Code contains legal requirements which direct schools to assess the English language proficiency of students. The process begins with determining the language(s) spoken in the home of each student. The responses to the home language survey will assist in determining if a student's proficiency in English should be tested. This information is essential in order for the school to provide adequate instructional programs and services.

As parents or guardians, your cooperation is requested in complying with these requirements. Please respond to each of the four questions listed below as accurately as possible. For each question, write the name(s) of the language(s) that apply in the space provided. Please do not leave any question unanswered. If an error is made completing this home language survey, you may request correction before your student's English proficiency is assessed.

1. Which language did your child learn when they first began to talk?*

Answer required for "1. Which language did your child learn when they first began to talk?"

2. Which language does your child most frequently speak at home?*

Answer required for "2. Which language does your child most frequently speak at home?"

3. Which language do you (the parents and guardians most frequently use when speaking with your child?*

Answer required for "3. Which language do you (the parents and guardians most frequently use when speaking with your child?"

4. Which language is most often spoken by adults in the home? (parents, guardians, grandparents, or any other adults)*

Answer required for "4. Which language is most often spoken by adults in the home? (parents, guardians, grandparents, or any other adults)"

Please sign and date this form in the spaces provided below. Thank you for your cooperation.

Signature*

Signature Required

California Department of Education Form HLS, Revised July 2020

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"