Language Usage Survey
Access this Language Usage PDF if you prefer that format.
Language Usage Survey for Parents and Guardians
Parents and Guardians: Please only complete this page of the survey. The back of this form will be completed by the school. A completed language usage survey is required for all students upon enrollment in Ohio schools. This information will tell school staff if they need to check your child’s proficiency in English. Answers to these questions ensure your child receives the education services to succeed in school. The information is not used to identify immigration status.
Student Name: (First Name and Last Name) _________________________
Student Date of Birth: (month/day/year) ___________________________
Communication Preferences
Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about their child’s education in a language they understand.
1. In what language(s) would your family prefer to communicate with the school?
Language Background
Information about your child’s language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.
2. What language did your child learn first?
3. What language does your child use the most at home?
4. What languages are used in your home?
Prior Education
Responses about your child’s birth country and previous education give us information about
the knowledge and skills your child is bringing to school and may enable the school to receive
additional funding to support your child.
5. In what country was your child born?
6. Has your child ever received formal education outside of the United States?
□Yes
□No
If yes, how many years/months?
If yes, what was the language of instruction?
7. Has your child attended school in the United States?
□Yes
□No
If yes, when did your child first attend a school in the United States?
Month/Day /Year: ______/_____/_________
Additional Information
Please share additional information to help us understand your child’s language experiences
and educational background.
Parent/Guardian First Name: _________________ Parent/Guardian Last Name: _______________
Parent/Guardian Signature: __________________ Today’s Date: (month/day/year) ____________
Thank you for providing the information above. Contact your school or district office if you have questions about this form or about services available at your child’s school. Translated information about schools’ civil rights obligations to English learner students and limited English proficient parents can be found here:
https://www2.ed.gov/about/offices/list/ocr/ell resources.html.
By Office of Superintendent of Public Instruction, licensed under a Creative Commons Attribution 4.0 International License.
***COMPLETED BY SCHOOL EMPLOYEE***
1.
Check. Confirm the following statements related to the administration of Ohio’s language usage survey:
□ The district or school presented the language usage survey, to the extent practicable, in a
language and form that the parent or guardian understood.
□ The district or school informed the parent(s) or guardian(s) of the form’s purpose. The language usage survey only is used to understand students’ linguistic experiences and educational background.
□ The district or school reports information from the language usage survey in the appropriate
Educational Management Information System (EMIS) records.
□ For students enrolling from other U.S. schools and districts, school officials request previous
language survey data and refer to the information when identifying English learners.
□ Results of the language usage survey are kept with the student’s cumulative records and follow the student if he/she transfers to another district or school.
2. Note. Record additional information to assist the review of the language usage survey.
3.
Record. Indicate responses from the language usage survey in the table below. Refer to the Language Usage Survey Annotations on page 2 for item-specific guidance.
Student’s native language: ____________________________________________
See Language Usage Survey Question 2.
Report for all students in EMIS.
_
Student’s home language: _____________________________________________
See Language Usage Survey Question 3.
Report only for English learners in EMIS.
_
Potential English learner: ______________________________________________
See Language Usage Survey Questions 2-4.
□ Yes. Assess the student’s English proficiency.
□ No. Do not assess the student’s English proficiency.
Immigrant student status: ____________________________________________
See Language Usage Survey Questions 5-7.
Report for all students in EMIS.
□ Yes, the student is an immigrant child.
□ No, the child is not an immigrant child.
4. Validate. Complete the information below.
Signature of validating school employee: ________________________________
Printed name of validating school employee: ____________________________
Date (mm/dd/year): ___________________________
Name of school or school district: ________________________________________
Last Modified: 8/15/2023 3:28:15 PM