PORTSMOUTH PUBLIC SCHOOLS

HOME LANGUAGE ASSESSMENT SURVEY

Student Name: ___________________________________________________________

(Last name) (First name) (Middle)

Date of Birth: ____________________________

School: _________________________________ Grade: ________

1. Which language did your child learn when he or she first began to talk? __________

2. What language does your child use most frequently with adults in the home?

_______________________________

3. Which language is used most frequently by the adults in your home? _____________

4. What language do you use most frequently to speak to your child? ______________

5. Name the language(s) spoken in your home: ________________________________

Signature of Parent or Guardian:_____________________________________________

Printed Name of Parent of Guardian: _________________________________________

Date: ________________________

02/00