The Civil Rights Act of 1964, Title VI, Language Minority Compliance Procedures, requires school districts and charter schools to determine the language(s) spoken in each student's home in order to identify their specific language needs. This information is essential in order for schools to provide meaningful instruction for all students as outlined Plyler v. Doe, 457 U.S. 202 (1982).

The purpose of this survey is to determine the primary or home language of the student. The HLS must be given to all students enrolled in the school district / charter school. The HLS is administered one time, upon initial enrollment in Indiana, and remains in the student's cumulative file.

Please note that the answers to the survey below are student-specific. If a language other than English is recorded for ANY of the survey questions below, the W-APT will be administered to determine whether or not the student will qualify for additional English language development support.

1. What is the native language of the student? _________________________________

2. What language(s) is spoken most often by the student? _________________________________

3. What language(s) is spoken by the student in the home? _________________________________

Student Name:________________________________________________ Grade:____________________

Parent/Guardian Name:___________________________________________________________________

Parent/Guardian Signature:__________________________________________Date:__________________

By signing here, you certify that responses to the three questions above are specific to your student. You understand that if a language other than English has been identified, your student will be tested to determine if they qualify for English language development services, to help them become fluent in English. If entered into the English language development program, your student will be entitled to services as an English learner and will be tested annually to determine their English language proficiency.