Pbv Application Packet - Housing Authority Of Snohomish County Page 37

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HOUSING AUTHORITY OF SNOHOMISH COUNTY
12711- 4
Avenue West • Everett, Washington 98204
th
PHONE (425) 290-8499 • FAX (425) 290-5618
Housing Authority of Snohomish County
Language Services Questionnaire
Dear Client:
The Housing Authority of Snohomish County wishes to determine the number of households that may be
in need of language services (interpretation & translation) for persons who have limited proficiency in
English. We request your help in making that determination. Please answer the questions below and
return this questionnaire to us as indicated.
1. What is the primary language used in your household?
Arabic
Cambodian
English
Farsi
Hmong
Japanese
Khmer
Lao
Russian
Somali
Spanish
Ukraine
Vietnamese
Other:
2. What languages are spoken in your household?
Arabic
Cambodian
English
Farsi
Hmong
Japanese
Khmer
Lao
Russian
Somali
Spanish
Ukraine
Vietnamese
Other:
3. Does at least one adult (a person 18 years of age or older) member of your household speak and read
English?
Yes. Please list the member’s name:
No
4. Does at least one adult (a person 18 years of age or older) member of your household read and write
English?
Yes. Please list the member’s name:
No
Please provide your name, address, and social security number. We will place this survey in your file and
will use it to provide language services that you may need in accordance with our Limited English
Proficiency Plan and Policies.
If you do not understand this survey, please contact your housing representative for assistance.
A copy of this survey will be translated for you free of charge if you are not able to read this
notice.
Equal Housing Opportunity

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