Language Usage Survey
Access this Language Usage Survey file if you prefer a different format.
Language Usage Survey for Parents and Guardians
Parents and Guardians: Ohio schools, in accordance with
The Every Student Succeeds Act, request all families complete a language usage survey when they enroll their student in school. This information will help school staff understand your child’s language background and your family’s preferred language communications to best support your child’s learning. 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 an interpreter or translations may be provided at no cost.
1. In what language(s) would your family prefer to communicate with the school?
Language Background
Information about your child’s language background is needed to identify whether students are screened for English learner status.
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 provide information about the knowledge and skills your child is bringing to school.
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
Share any information to better understand your child’s language experiences and 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.
Last Modified: 8/21/2024 3:49:11 PM