Home Language Usage Survey
The Home Language Usage Survey is completed by all students initially enrolling in Arkansas schools.
Email *
Date: *
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Student Name: *
Grade: *
Date of Birth: *
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Gender: *
Student State ID:
Parent/Guardian Name: *
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? *
1.) 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 students who may qualify for 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) *
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9.) Has your child attended a school in Puerto Rico? *
Electronic Signature
By typing your name below, you are signing this form electronically. You agree that your electronic signature is the equivalent of your manual signature on this form.
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Thank you for providing the information needed on the Home Language Usage Survey. Please contact us if you have further questions about this form or about services available at our school.
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