Page 19 - 2016 Handbook FINAL 4.18.16
P. 19
APPENDIX A: Language Use Survey
Building _____________
Troy School District Language Use Survey Grade ________
Student Information
Last Name First Name
Birthdate(mm/dd/yyyy) Phone Number
Date FIRST Arrived in US if not born in the US Parent Email Address
Country of Birth City of Birth
School Information
Has the student EVER lived in the US? circle one YES NO
When did the student last live in the US? (mm/dd/yyyy) _______________________________________________________
Has the student ever attended a US school? circle one YES NO
Name the last US school attended? _________________________________________________________________________________
When did your child attend this school? ___________________________________________________________________________
City and State of last school attended? ____________________________________________________________________________
Has your child missed school for an extended period of time (interrupted school)? __________________________
________________________________________________________________________________________________________
Language Use Information
Is your child’s native (first) language a language other than English?
circle one YES NO What is the language? _______________________________________________________________
Is the primary (main) language used in your child’s home a language other than English?
circle one YES NO What is the language? _______________________________________________________________
What language do you use most frequently to speak to your child? _____________________________________________
Which language is most often used by the adults in the home? __________________________________________________
Do you need translation services for school communications? circle one YES NO
Siblings (Brother and Sisters)
Siblings Name School Name Grade Brother/Sister
