D OF E Home Language Survey

Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School:
The Delaware Department of Education requires schools to determine the language(s) spoken at home by each student. The information provided will only be used to determine whether your student is eligible to begin the English as a Second Language process and will not be used for immigration matters or reported to immigration authorities.
Student Information
First Name:
Last Name:
Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Country of birth:
Date of entry in the US:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date student first enrolled in a US school:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Select grades your child attended in US schools
How many total months has the student been enrolled in a US school?
1. What language did your child first learn?
Language: Type here Dialect: Type here
2. What language does your child most often use at home?
Language: Type here Dialect: Type here
3. What languages do you most often speak to your child?
Language: Type here Dialect: Type here
4. What language(s) other than English are spoken in your home?
Language: Type here Dialect: Type here
5. What language would you prefer to receive information from your school?
Language: Type here Dialect: Type here
Parent's Name

First NameLast Name
Parent Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
LEA : Please have all families complete this home language survey at the student’s initial enrollment in school. This form must be signed and dated by the parent or guardian and kept in the student’s file. (If a language other than English or Non-US English is listed on questions 1-3, the LEA must continue with a records review, step 2 of the English learner identification process
THE DELAWARE DEPARTMENT OF EDUCATION IS AN EQUAL OPPORTUNITY EMPLOYER. IT DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, MARITAL STATUS, DISABILITY, AGE, GENETIC INFORMATION, OR VETERAN’S STATUS IN EMPLOYMENT, OR ITS PROGRAMS AND ACTIVITIES.
Should be Empty:

Student Information