English Learner Identification and Service Plan Documentation

Documents the home-language survey, English learner identification, placement decision, and annual service plan for students who may qualify for EL services.

Submission Notice and Privacy Disclosure

• I understand this form is used to document EL identification and service planning.
• I acknowledge that student information will be used only for educational placement, service planning, and compliance purposes.
• Consent to collect and use language background information for educational placement
• Who is completing this form?

Student and Case Identification

• Student ID
• Student Name
• Date of Birth
  Collect only if needed to match the student record.
• School Name
• Grade Level

Home-Language Survey

• What language is most often spoken at home?
• What was the first language the student learned?
• Other languages used by the student or family
• Has the language used at home changed since the last school year?
• Describe the change in language background
  Briefly describe the change and when it occurred.

EL Identification and Placement

• Was a language screening completed?
• Screening Date
• Screening Result
• English Learner Identification Status
• Placement Decision
• Placement Notes
  Include only placement details needed for service delivery.

Annual EL Service Plan

• Service Year
• Service Model
• Service Frequency
• Minutes of EL Support per Week
• Language Support Goals
  Summarize the annual language development goals and supports.
• Review Date

Team Members and Sign-Off

• Case Manager Name
• Guardian acknowledgement received
• Team Members
• Final Comments