PARENT LANGUAGE QUESTIONNAIRE 1. First language learned ...
PARENT LANGUAGE QUESTIONNAIRE 1. First language learned ...
PARENT LANGUAGE QUESTIONNAIRE 1. First language learned ...
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<strong>PARENT</strong> <strong>LANGUAGE</strong> <strong>QUESTIONNAIRE</strong><br />
Part I. Language Background<br />
A. Student _______________________________ Sex (M/F) ______ Date of Birth ______________ Grade ________<br />
Address __________________________________________________ Phone ____________________<br />
School ________________________________________________<br />
<strong>1.</strong> <strong>First</strong> <strong>language</strong> <strong>learned</strong> by the student _______________________<br />
2. Was the student’s primary <strong>language</strong> ever a <strong>language</strong> that was not English? ______ Yes ______ No<br />
B. Mother’s Name ___________________________________ Original Community ___________________________<br />
<strong>1.</strong> <strong>First</strong> <strong>language</strong> <strong>learned</strong> by mother ________________________________________<br />
2. Language(s) mother speaks to the student __________________________________<br />
3. Language(s) mother speaks in the home ___________________________________<br />
4. Does the mother understand a <strong>language</strong> that is not English? ______ Yes ______ No<br />
If the mother understands a <strong>language</strong> that is not English, which <strong>language</strong> is it? _________________________<br />
C. Father’s Name ___________________________________ Original Community ___________________________<br />
<strong>1.</strong> <strong>First</strong> <strong>language</strong> <strong>learned</strong> by father _________________________________________<br />
2. Language(s) father speaks to the student __________________________________<br />
3. Language(s) father speaks in the home ___________________________________<br />
4. Does the father understand a <strong>language</strong> that is not English? ______ Yes ______ No<br />
If the father understands a <strong>language</strong> that is not English, which <strong>language</strong> is it? __________________________<br />
D. Does anyone other than the parents living in the child’s home speak a <strong>language</strong> that is not English?<br />
______ Yes ______ No If yes, what <strong>language</strong> is spoken? __________________________<br />
What is the relationship of the person(s) to the student?<br />
_____ Grandmother _____ Aunt _____ Brother _____ Other: Who? ______________________<br />
_____ Grandfather _____ Uncle _____ Sister<br />
E. Does anyone, besides the people list above, regularly speak to your child in a <strong>language</strong> that is not English?<br />
______ Yes ______ No<br />
If yes, what <strong>language</strong> is spoken? __________________________<br />
What is the relationship of the person(s) to the student?<br />
_____ Grandmother _____ Aunt _____ Brother _____ Friend/Playmate<br />
_____ Grandfather _____ Uncle _____ Sister _____ Other: Who? _________________________<br />
Where do they speak and how often? ___________________________________________________<br />
II. Parent Verification of Language Use<br />
(PLEASE COMPLETE OTHER SIDE)<br />
A. When the student speaks with you, or other family members, s/he speaks:<br />
_____ No English<br />
_____ Mostly a <strong>language</strong> other than English<br />
_____ The other <strong>language</strong> and English equally
_____ Mostly English, and is able to speak some phrases in ________________________ (name of <strong>language</strong>)<br />
_____ Only English<br />
B. When the student speaks with friends, s/he speaks:<br />
_____ No English<br />
_____ Mostly a <strong>language</strong> other than English<br />
_____ The other <strong>language</strong> and English equally<br />
_____ Mostly English, and is able to speak some phrases in ________________________ (name of <strong>language</strong>)<br />
_____ Only English<br />
C. The student understands a <strong>language</strong> that is not English although s/he does not speak the <strong>language</strong> him/herself<br />
_____ Yes _____ No If yes, what <strong>language</strong> does s/he understand _______________________<br />
In what setting? ____________________________________________________________________<br />
How well does s/he understand the <strong>language</strong> other <strong>language</strong><br />
_____ Comprehends stories and conversations in a <strong>language</strong> that is not English<br />
_____ Can follow directions or commands (including games & dances) in a <strong>language</strong> that is not English<br />
_____ Comprehends words of joy, sadness, anger (emotional terms) in a <strong>language</strong> that is not English<br />
_____ Understands basic vocabulary words and greeting in a <strong>language</strong> that is not English<br />
_____ No understanding of a <strong>language</strong> that is not English<br />
Thank you for supporting your child’s education.<br />
____________________________________________________<br />
___________________________<br />
Parent Signature Date<br />
Revised 3/20/05 - 5a -
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