Please fill out the DSHS Background Application first. https://fortress.wa.gov/dshs/bcs/. You will need the Confirmation Number to complete this form.
All Sign Language Interpreters are required to fill out DSHS background check authorization application online. https://fortress.wa.gov/dshs/bcs
Once you fill out the online application, you will receive a confirmation code via email. Please add that code below.
Confirmation Code
I am currently working as a subcontractor/employee with the following Interpreter Referral Agenc(ies): (check all that apply) I understand that the Interpreter Referral Agencies will verify my insurance information. If I am not linked with an agency, my name will be removed from the ODHH list.
DES Contract:
Crucial Service:
I am an Independent Contractor with the State of Washington. My contract number is
Please select your credentials below. For information on approved BEI and/or RID Certifications, check with your Vender. Qualified Deaf Interpreters, PreCertified and non Certified status needs to be selected.
My certification is
and I became certified on
My certification is
and I became certified on
My certification is
and I became certified on
My certification is
and I became certified on
ODHH must have a copy of my initial Certification on file to verify my rate. If requested, I will submit a copy of my Certification or a verification letter from RID or BEI within 14 business days.
I have training in the following and I am willing to interpret in the following settings (check all that apply):
I was
years old when I started signing. My background in sign language started because (check all that apply):
Parents, family members
Deaf friend(s)
Became involved with the Deaf community
Took ASL/Deaf studies course(s) in high school
Took ASL/Deaf studies course(s) at a college/university
Took ASL/sign language course(s) at:
nonprofit serving deaf
adult education
I have a high school diploma or GED equivalent:
My background in education and training is as follows:
Hearing Identity:
Do you have Deaf family members?
No
Deaf Parent(s)
Deaf Sibling(s)
Deaf Spouse
Other
Gender:
Are you of Hispanic Origin? Yes, I am of Hispanic origin. No
The Spanish/Hispanic/Latino question is about ethnicity, not race. Please continue to the following list by marking one or more boxes to indicate what you consider your race to be (check all that apply):
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Other
If you checked any of the questions above, please explaining the circumstances in detail. Please be sure to provide the date, the state, and information regarding the crime and/or findings.
Explanation:
“Confidential Information” means information that is exempt from disclosure to the public or other unauthorized persons under Chapter 42.56 RCW or other federal or state laws. Confidential Information includes, but is not limited to, protected health information as defined by the federal rules adopted to implement the Health Insurance Portability and Accountability Act of 1996, 42 USC §1320d (HIPAA), and Personal Information.
“Personal Information” means information identifiable to any person, including, but not limited to, information that relates to a person’s name, health, finances, education, business, use or receipt of governmental services or other activities, addresses, telephone numbers, social security numbers, driver license numbers, other identifying numbers, and any financial identifiers or as otherwise identified in RCW 42.56.230.
State laws (including RCW 74.04.060 and RCW 70.02.020) and federal regulations (including HIPAA Privacy and Security Rules; 42 CFR, Part 2; 42 CFR Part 431) prohibit unauthorized access, use, or disclosure of Confidential Information. Violation of these laws may result in criminal or civil penalties or fines. You may face civil penalties for violating HIPAA Privacy and Security Rules up to $50,000 per violation and up to $1,500,000 per calendar year as well as criminal penalties up to $250,000 and ten years imprisonment.
When any State Department, Agency or Contracted Service Provider grants me access to state property, systems, and Confidential Information, I agree that I: (must check all)
I understand that if any of information provided above is found to be false, it may preclude me from providing services under the ODHH-DES Master Contract. This document is signed and sworn under penalty of perjury. I certify that the above information is true and correct.
My signature on this registration form authorizes ODHH and DES to review and/or obtain conviction records from the Washington State Patrol and other states; and to obtain from Washington and other states licensing information and any determination or finding of abuse, neglect or exploitation.
I understand that the results of this background check will be kept in total confidence and may be released or reviewed by ODHH and/or DES when monitoring contract compliance. Any convictions or findings resulting after ODHH registration and approval shall be reported to ODHH within two working days.
Please sign.
Signed on Date:
