Orange Unified School District Home Language Survey -English
Student's Last Name:
First Name:
Middle:
School (OUSD):
Grade:
Age:
Birth Date:
Student #:
The California Education Code requires schools to determine the language(s) spoken at home by each student. This information is essential in
order for the school to provide adequate instructional programs and services. Your cooperation in helping us meet this important requirement is
requested. Please answer the following questions and return this form to the school office. Thank you for your help.
1. Which language did your son or daughter learn when he or she first began to talk?
2. What language does your son or daughter most frequently speak at home?
3. What language do you use most frequently when speaking with your son or daughter?
4. What language is spoken most often by the adults in the home?
Signature of Parent/Guardian:
Date:
To comply with federal guidance issued by the U S. Department of Education regarding the collection of student race and ethnicity data, we
request your answers to the following two questions. (Federal Register, Vol. 72, No.202) Also, as part of the California State Assessment Program,
we are required to submit to the State, information on student ethnicity that is meant to help assure that all student groups are making adequate
progress. Please be assured that all responses will be kept confidential.
Please answer questions 1 AND 2
1. Ethnicity
Is this student Hispanic or Latino. (Select only one)
No, not Hispanic or Latino
Yes, Hispanic or Latino
;
The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by
marking one or more boxes to indicate what you consider your race to be.
2. Race What is the race of this student? (Circle one or more)
2.
Race
What is the race of this student?
(Circle one or more)
American Indian or Alaskan Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Hmong
Japanese
Korean
Laotian
Other Asian
Other Pacific Islander
Samoan
Tahitian
Vietnamese
White
OUSD Revised 03/19 white copy-cumulative file yellow copy-Language Assessment Center
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