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Home Language Survey 2021-22

Home Language Survey

For the 2021-22 School Year (New Students Only)

The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student’s home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982).

The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment in Indiana, and remains in the student's cumulative file.

Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the survey questions below, the W-APT or WIDA Screener will be administered to determine whether or not the student will qualify for additional English language development support.

Please answer the following questions regarding the language spoken by the student:

Please complete the form below. Required fields marked with an asterisk *

Name of Student:*

Answer Required

Grade for the 2021-22 School Year: *

Answer Required

Was the student born outside of the United States?*

Answer Required

Yes

If the student was born outside of the United States - How many years has the student lived in the United States?

Answer Required

If the student was born outside of the United States - How many years have they attend school in the United States?

Answer Required

What is the native language of the student?*

Answer Required

What language(s) is spoken most often by the student?*

Answer Required

What language(s) is spoken by the student in the home?*

Answer Required

Parent's Name: *

Answer Required

Parent's Signature:*

Answer Required

Date:*

Answer Required

By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.

Confirmation Email

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