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Home Language Questionnaire

Required

STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of P-12

Lissette Colon-Collins, Assistant Commissioner
Office of Bilingual Education and World Languages

55 Hanson Place, Room 594
Brooklyn, New York 11217
Tel: (718) 722-2445 / Fax: (718) 722-2459

89 Washington Avenue, Room 528EB
Albany, New York 12234
(518) 474-8775 / Fax (518) 474-7948

Home Language Questionnaire (HLQ)

Dear Parent or Guardian:
In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English, as well as prior school and personal history. Please complete the sections below entitled Language Background and Educational History. Your assistance in answering these questions is greatly appreciated. Thank you.

Student Name:required
First Name
Middle (optional)
Last Name
Must contain a date in MM/DD/YYYY format
Gender:required
Parent/Person in Parental Relation Info:required
First Name
Last Name

Language Background
(Please check all that apply.)

1. What language(s) is(are) spoken in the student(s) home or-residence?required
specify
2. What was the first language your child learned?required
specify
3. What is the Home Language of each parent/guardian?required
specify
4. What language(s) does your child understand?required
specify
5. What language(s) does your child speak?required
specify
6. What language(s) does your child read?required
specify
7. What language(s) does your child write?required
specify

THIS SECTION TO BE COMPLETED BY DISTRICT IN WHICH STUDENT IS REGISTERED

Home Language Questionnaire (HLQ) - Part Two

Educational History

9. Do you think your child may have any difficulties or conditions that effect his or her ability to understand, speak, read or write in English or any other language? If yes, please describe them.required
How severe do you think these difficulties are?
10a. Has your child ever been referred for a special education evaluation in the past?required
10b. *If referred for an evaluation has your child ever received any special education services in the past?
Age at which services were received (Please check all that apply)
10c. Does your child have an Individualized Education Program (IEP) ?
Attach up to 1 file with a maximum size of 10MB
No file chosen
Must contain a date in MM/DD/YYYY format
Relationship to Studentrequired
Official Entry Only - Name/Position of Personal Administering (HLQ)
Name:
First Name
Last Name

IF ANY INTERPERETER IS PROVIDED, LIST NAME, POSITION AND CREDENTILES

Name Position of Qualified Personnel Reviewing HLQ and Conducting Individual Interview 

Name:
First Name
Last Name
Oral Interview Necessary

Name/Position of Qualified Personnel Administering NYSITELL

Name:
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Proficiency Level Achieved on NYSITELL

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