SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

Texas Education Agency -- Division of Bilingual Education

Home Language Survey

20__-20__

Student Name ___________________________________________ Grade ____________

Student Name ___________________________________________ Grade ____________

Student Name ___________________________________________ Grade ____________

Student Name ___________________________________________ Grade ____________

To be completed by parent or guardian:

1. What language is spoken in your home most of the time? _______________________
2. What language does your child speak most of the time? ________________________

___________________________________

Signature of Parent/Guardian

______________________

Date

If your child does not speak English most of the time, or if the language spoken in your home most of the time is not English, your child will be tested to see if he or she needs assistance from the school to learn English.

II. 24