The 
Office 
of 
Civil 
Rights 
(OCR) 
requires 
that 
school 
districts/charter 
schools/full 
day 
AVTS 
identify 
Limited 
English 
Proficient 
(LEP) 
students 
in 
order 
to 
provide 
appropriate 
language 
instructional 
programs 
for 
them. 
Pennsylvania 
has 
selected 
the 
Home 
Language 
Survey 
as 
the 
method 
for 
the 
identification. 
(Date) 
(School) 


School: 
________________________________________ 
Date: 
__________________ 
(Grade) 
(Student’s name) 


Student’s 
name: 
__________________________________________ 
Grade: 
___________ 
(Country of origin) 


Country 
of 
origin: 
_____________________________________________________________ 
(What is/was the student’s first language) 


1. 
What 
is/was 
the 
student’s 
first 
language? 
____________________________________ 
2. 
Does 
the 
student 
speak 
a 
language(s) 
other 
than 
English? 
(Do 
not 
include 
languages 
learned 
in 
school.) 
YES 
(What language(s) is/are spoken in your home) 
NO 



(: Yes) Unchecked
(: Yes) Unchecked
3. 
What 
language(s) 
is/are 
spoken 
in 
your 
home? 
________________________________ 
4. 
Has 
the 
student 
attended 
any 
other 
United 
States 
school 
in 
any 
three 
(3) 
years 
during 
his/her 
lifetime: 
YES 
NO 



(: Yes) Unchecked
(: 2) Unchecked
If 
yes, 
complete 
the 
following: 


Name 
of 
School 
State 
Dates 
attended 
(Dates attended [1]) 
(Dates attended [2]) 
(Dates attended [3]) 
(Person completing this form (if other than parent/guardian) 
(State [1]) 
(State [2]) 
(State [3]) 
(Name of School [1]) 
(Name of School [2]) 
(Name of School [3]) 


Person 
completing 
this 
form 
(if 
other 
than 
parent/guardian): 
____________________________ 


Parent/guardian 
signature: 
_____________________________________________________ 


*The 
school 
district/charter 
school/full 
day 
AVTS 
has 
the 
responsibility 
under 
the 
federal 
law 
to 
serve 
students 
who 
are 
Limited 
English 
Proficient 
(LEP) 
and 
need 
English 
instructional 
services. 
Given 
this 
responsibility, 
the 
school 
district/charter 
school/full 
AVTS 
has 
the 
right 
to 
ask 
for 
the 
information 
it 
needs 
to 
identify 
English 
Language 
Learners 
(ELLs). 
As 
part 
of 
the 
responsibility 
to 
locate 
and 
identify 
ELLS, 
the 
school 
district/charter 
school/full 
day 
AVTS 
may 
conduct 
screenings 
or 
ask 
for 
related 
information 
about 
students 
who 
are 
already 
enrolled 
in 
the 
school 
as 
well 
as 
from 
students 
who 
enroll 
in 
the 
school 
district/charter 
school/full 
day 
AVTS 
in 
the 
future. 


Revised 
2/2011