Aging and Long-Term Support Administration

Sign Language Interpreter Registration Form

Personal Information
Applying for registry with:
First Name:  
Middle Initial:
Last Name:  
Date of Birth:
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Street Address:
City:  
State:
Zip Code:
County of Residence
First Telephone Number (Including Area Code):
    |  
Second Telephone Number (Including Area Code):
       |  
Email Address:     Home Work Mobile
Email Address:   Home Work Mobile
Availability

I am currently working 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.


I am an Independent Contractor with the State of Washington. My contract number is :

Communication Preference (check all that apply)
American Sign Language Signing Exact English
Tactile Sign Language
Pidgin Signed English
Close-Vision Sign Language
Pro-Tactile
International Sign Language Type in International Sign Language:

 
Certification

I am a RID Certified Sign Language Interpreter.
My certification is  and I became certified on
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My certification is  and I became certified on
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My certification is  and I became certified on
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My certification is  and I became certified on
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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 within 14 business days.

Experience/Setting
I started working in the sign language interpreting profession on (MM/YYYY):  /  
I have training in the following and I am willing to interpret in the following settings (check all that apply):
Mental Health
Drug and Alcohol
Children Protective Service
Adult Protective Service
Medical
Socio-Economics Benefits
Platform
K-12 Education
Post-Secondary Education
Rehabilitation/Vocational
Adult Education
Technology
Legal:
Court
Administrative Hearing
Law Enforcement



Education and Training

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:

NAME OF SCHOOLTYPE OF DEGREE FIELD OF STUDYITP?NUMBER OF YEARS ATTENDED GRADUATION DATE (MM/YYYY)
AA BA MA PHD
      
AA BA MA PHD
     
AA BA MA PHD
     
AA BA MA PHD
     

Demographic Information - Optional

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

Self-Disclosure (please review and check all that apply to you)

Has your RID or BEI certification ever lapsed?
Have you ever had any substantiated allegations of code of ethics violation pertaining to interpreting practice by any certifying body or other agency?
Have you ever had an Interpreter Quality Assurance credential/state licensure denied, revoked, or suspended?
Do you currently have any pending actions related to a denial, revocation, or suspension of any interpreter credential/licensure?

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:
 

Background Check

All Sign Language Interpreters are required to fill out DSHS background check authorization applicaon online. https://fortress.wa.gov/dshs/bcs

Once you fill out the on-line application, you will receive a confirmation code via email. Please add that code below.

Confirmation Code:

Confidential Agreement per DSHS Form 03-374b

“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.

Assurance of Confidentiality

In consideration for the Department of Social and Health Services (DSHS) and any other agency granting me access to state property, systems, and Confidential Information, I agree that I: (must check all)

Will not use, publish, transfer, sell or otherwise disclose any Confidential Information gained by reason of this agreement for any purpose that is not directly connected with the performance of the contracted services except as allowed by law.
Will protect and maintain all Confidential Information gained by reason this agreement against unauthorized use, access, disclosure, modification or loss.
Will employ reasonable security measures, including restricting access to Confidential Information by physically securing any computers, documents, or other media containing Confidential Information.
Have an authorized business requirement to access and use DSHS systems or property, and view its data and Confidential Information if necessary.
Will access, use and/or disclose only the “minimum necessary” Confidential Information required to perform my assigned job duties.
Will not share DSHS system passwords with anyone or allow others to use the DSHS systems logged in as me.
Will not distribute, transfer, or otherwise share any DSHS software with anyone.
Understand the penalties and sanctions associated with unauthorized access or disclosure of Confidential Information.
Will forward all requests that I may receive to disclose Confidential Information to my supervisor for resolution.
Understand that my assurance of confidentiality and these requirements do not cease at the time I terminate my relationship with my employer or DSHS.

Declaration

I have read and understand the current NAD-RID Code of Professional Conduct and agree to abide by it.
I have read and understand the BEI Code of Professional Conduct and agree to abide by it.
I understand that some of my information will be posted on the DSHS website and/or in the Directory of Services.
I am a Qualified Deaf Interpreter, I have read and understand the DSHS Code of Professional Conduct and agree to abide by it.

I understand that if any of information provided above is found to be false, it may preclude me from providing services under the DSHS and/or HCA 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 DSHS/ODHH 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 DSHS when monitoring contract compliance.  Any convictions or findings resulting after ODHH registration and approval shall be reported to ODHH within two working days.


Signed on Date: 
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Registration Submittal