Home Language Usage Survey (DESE)

Arkansas Division of Elementary and Secondary Education (DESE) Home Language Usage Survey
The Home Language Usage Survey is completed by all students initially enrolling in Arkansas schools.
Student Name
Grade
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School
Student State ID #:
Gender:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name
Parent/Guardian Signature

Right to Translation and Interpretation Services

Indicate your language preference so we can provide an interpreter or translated documents, free of charge, when you need them.

All parents have the right to information about their child’s education in a language they understand.
1. a) In what language do you prefer to receive written communication from the school?
b) In what language would you prefer to communicate with school staff when speaking?

Eligibility for Language Development Support

Information about the student’s language usage helps us identify extended 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(s) is (are) spoken in your home?
3. What language did your child learn first?
4. What language does your child use most often at home?
5. What language does your family speak most often at home?
6. What language do adults speak most often with each other at home?

Prior Education

Your responses about your child’s birth country and previous education give us information about the knowledge and skills your child is bringing to school.
This form is not used to identify students’ legal immigration status.

7. Where was your child born?
8. When did your child first attend a school in the United States (the 50 states, DC)? (Kindergarten – 12th grade)
Month
Day
Year
9. Has your child attended a school in Puerto Rico?
Thank you for providing the information needed on the Home Language Usage Survey. Contact your child’s school if you have further questions about this form or about services available at your child’s school.

Note to district: This form is available in multiple languages on http://www.arkansased.gov/divisions/learning-services/english learners A response that includes a language other than English to questions #1-6 indicates English language proficiency screening is needed. This work, "Arkansas Department of Education (ADE), Home Language Survey", is a derivative of "OSPI Home Language Survey" by OSPI, used under CC BY . "Arkansas Department of Education (ADE), Home Language Survey" is licensed under CC BY by the English Learners Unit of the Arkansas Department of Education.
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Arkansas Division of Elementary and Secondary Education (DESE) Home Language Usage Survey