Form H Dg - Home Language Survey printable pdf download

NORTH PENN SCHOOL DISTRICT

LANSDALE, PA. 19446

HOME LANGUAGE SURVEY*

The Office of Civil Rights (OCR) requires that school districts/charter schools/full day AVTS identify limited

English proficient (LEP) students in order to provide appropriate language instructional programs for them.

Pennsylvania has selected the Home Language Survey as the method for the identification.

Student’s Name: __________________________________________________Grade: _______________

School:_____________________________

Date: ________________

1. What was the student’s first language? __________________________

2. Does the student speak a language(s) other than English?

(Do not include languages learned in school.)

Yes

If yes, specify the language(s): ____________________________________

3. What language(s) is/are spoken in your home? ______________________

4. City of birth: __________________________ State of birth:_______________________

If your child was not born in this state, what was his/her date of entry into

Pennsylvania? _____________

5. Country of birth: ________________________

If your child was not born in this country, what was his/her date of entry into the

United States?______________

To assist the school district to comply with Federal Mandate reporting, please check one of the following:

Black Non-Hispanic

American Indian

Asian

White Non-Hispanic

Hispanic

Parent/Guardian signature:__________________________________________________________________

Person completing this form (if other than parent/guardian):______________________________________

*The school district/charter school/full day AVTS 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/full day

AVTS 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/full day AVTS may conduct screenings or ask for related information

about students who are already enrolled in the school as well as from students who enroll in the school district/charter school/full

day AVTS in the future.

H.dgForms 12/07

Form H Dg - Home Language Survey