Join Us - Survey

*Required Fields
This survey form should be completed by an authorized organizational representative. Submissions are subject to review before acceptance and publication.
To update information for an existing agency, please use the Change Request Form.

Contact Information:

*Name of Organization:  
*Mailing Address:

         City:  County:    

         State:   Zip:    

*Phone Number(###-##-####): - Ext:         
Fax Number(###-##-####):  

*E-mail Address:    

Web Site Address:  

*Contact Person: First Name:   Last Name:  

*Services Provided:   

Please indicate the type of organization that you work for. You may check off one or more categories. If a service is missing from the list, you can write it in on the bottom.

Other Services:(100 characters max)
New Service 1:  
New Service 2:  
New Service 3:  

*Briefly describe some of the specific services you provide (750 characters max):

*Counties Served:    

Please check all the counties your organization serves.

Language Communities Served:

For the limited English proficient language communities that you can serve within your organization, please specify how you communicate orally with these communities and enter the qualification code(s) for the most qualified person providing such services.
-- Please note that this question is for the purpose of showing service capacity in non-English language, not the number of people providing such service.
-- A list of qualification codes (1-9) can be found below the grid. Use as many of them as applicable. Please separate code numbers with commas, e.g. 4,5,6.
-- Please do NOT include telephonic interpreting or video remote interpreting in your answer to this question.
-- Mouse over on column headings for the definitions of each language modality.
Program staff with bilingual or multilingual skillsAn employee who is a proficient speaker of two or more languages and may provide direct services in non-English language
DUAL-ROLE interpreterA bilingual employee in health care or community setting who has been tested for language skills, trained as an interpreter and who has assumed the task of part-time interpreting willingly
Contract interpreterA dedicated interpreter who is not an employee of the organization or institution and is contracted, most likely through an interpreting agency, to provide interpreting services for a set amount of time
Dedicated interpreterAn individual whose sole responsibility within an organization or institution is to provide interpreting services or, in other words, to facilitate communication between two or more parties who don’t share the same language, and does not have any other duties beyond interpreting
American Sign Language    
Amharic (Ethiopian)    
Chinese (Cantonese)    
Chinese (Fujianese)    
Chinese (Mandarin)    
Dzongkha (Bhutanese)    
Haitian Creole    
Persian (Farsi)    
Portuguese Creole    
Other Languages:

Qualification Codes:
Code Description
1 Native speaker (self-identified) with fluency in non-English language documented through oral proficiency test
2 Native speaker (self-identified) with fluency in non-English language documented through academic degree earned in non-English language
3 Native speaker (self-identified) with fluency in non-English language documented through other reliable means
4 Native speaker (self-identified) with English skills demonstrated through successful completion of coursework at the post-secondary level, passage of the Test of English as a Foreign Language (TOEFL) (or other equivalent test), or other reliable means
5 Non-native speaker with fluency in foreign language documented through oral proficiency test
6 Non-native speaker with fluency documented through successful completion of extensive coursework in foreign language at the post-secondary level and/or living or working in a foreign country for an extended period of time
7 Non-native speaker with fluency in foreign language documented through other reliable means
8 Interpreter with certification from a national or state certifying body
9 Interpreter who passed a validated oral proficiency test and received 40 or more hours of interpreter training

Other Accommodations Provided:   

*Which of the following remote interpreting services does your agency subscribe to?

*Does your agency provide textual information to clients in non-English language? If yes, please indicate how documents are translated.

*Please indicate which forms of assistive technology or resources are available through your organization to serve people with disabilities?

*Has your agency provided cultural competency training to your staff within the last three years?

If yes, please describe the type(s) of training provided (300 character maximum)