Olympic Educational Service District 114

105 National Avenue North, Bremerton, Washington 98312

(360) 478-6887  1-800-201-1300  FAX (360) 405-5808

HOME LANGUAGE SURVEY

Child’s Name: Click or tap here to enter text. Classroom: Click or tap here to enter text.

Staff Completing Form: Click or tap here to enter text. Date Completed: Click or tap to enter a date.

The English Language Acquisition objectives are to be used as needed with children age 3 and older whom you classify as English or dual-language learners. In order to determine whether or not to use the English Language Acquisition objectives (Objectives 37 & 38), you will need to gather information about what language the child and their family members use at home, and what language the child uses while they talk with the teachers and other children in the classroom. While the English Language Acquisition objectives are not used with very young children, this information should still be collected as useful background information.

Answer the following questions about the child and the family members who care for the child. You will respond by using a scale ranging from "only English" to "only home language." Try to gather as much information as possible to help you answer the questions. If you are unable to answer a question because you do not know the answer or because the child is not yet speaking, select N/A (not applicable).

A – What language do family members use when speaking to the child in the home? Choose an item.

Home Language 1: Click or tap here to enter text.

Home Language 2: Click or tap here to enter text.

B – What language does the child use when speaking to family members in the home? Choose an item.

C – What language does the child use when speaking to other children in the classroom? Choose an item.

D – What Language does the child use when speaking to the teachers? Choose an item.

Additional Notes (if applicable): Click or tap here to enter text.