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INTERPRETER ENTRY FORM

Personal Information

First name (required)

Middle Name (required, if you don't have a middle name type "none" in quotation marks)

Last Name (required)

Gender: Male Female (required)

Date of Birth:
Month Day Year (required)

Contact Information

Primary Contact Phone Number for Interpreting Assignments (required)

Street (optional)

City (required) State, Territory, Province (required)

Zip Code (required)

Country (required)

Email Address (primary) (optional) Email Address (secondary) (optional)

Phone number (day) (optional) Phone number (evening) (optional)

Phone number (cell) (optional) Pager number (optional)

Webpage

Additional Personal Information (optional)

Where I was born: (optional)

Where I grew up: (optional)

Religion: (optional)

Other information (e.g. dialect, ethnic group, special accommodations, special knowledge): (optional)

Languages Interpreted (Required)

Alphabetical list of 20 most commonly interpreted languages in MN.

Amharic/Ethiopian	Anuak	Arabic-Standard
Arabic-Sudanese	Bosnian	Chinese, Mandarin
Dinka	Hmong, White	Hmong, Green
Karen	Khmer (Cambodian)	Korean
Lao	Nuer	Oromo
Polish	Russian	Somali
Spanish	Tigrinyan	Vietnamese

Alphabetical list of 300+ languages.

Code of Ethics and Standards of Practice

National Code of Ethics for Interpreters in Health Care, July 2004
National Standards of Practice for Interpreters in Health Care, September 2005

I have read and agree to subscribe to the National Standards of Practice for Interpreters in Health Care and the National Code of Ethics for Interpreters in Health Care of the Nationa Council on Interpreting in Health Care.

Initial here (required)

Interpreting Skills Tests

I have taken an interpreting skills test and have attached a copy of the offical score report: (required)

I have passed the Consortium for State Court Interpreter Certification Oral Exam or the Federal Court Interpreter Certification Oral Exam or the Washington State Medical Interpreter Certification Exam: (required)


Governmentally Designated Interpreter Oral Certification Exams

Consortium for State Court Interpreter Certification Oral Exam					Language	for more information click here
	Passed?	% Sight	% Consecutive	% Simultaneous	Upload score report	for more information click here
	70% in each section is passing

Federal Court Interpreter Certification Oral Exam					Language	for more information click here
	Passed?				Upload score report	for more information click here
	80% overall is passing

Washington State Medical Interpreting Certification Exam					Language
(Still working on the reporting field form)					Upload score report	for more information click here
Interpreter Skills Tests (More tests may be added)
Arizona Medical Interpreter Competency Exam					Language
(Still working on the reporting field form)					Upload score report	for more information click here

Language Line Interpreting Tests						for more information click here
Language Line Medical Certification Test--Consecutive interpreting					Language Upload score report
	Passed?
	70% is passing
Language Line Court Certification Test--Consecutive interpreting					Language Upload score report
	Passed?
	70% is passing
Language Line Interpreter Skills Test--Consecutive interpreting					Language Upload score report
	Passed?

Language Line Language Proficiency Test					Language Upload score report
	Rating


JustTesting (Oregon)					Language
(Still working on the reporting field form)					Upload score report	for more information click here

NetworkOmni					Language
(Still working on the reporting field form)					Upload score report	for more information click here

Pacific Interpreters					Language
(Still working on the reporting field form)					Upload score report	for more information click here

Other					Language
Score information					Upload score report

Translation Skills Tests

I have passed an ATA Translation Certification Exam : (required)

I am currently certified by the ATA as a translator: (required)

*American Translators Association Translation Certification Exam*
		From	To
	Language Pair 1:			Upload score report
	Language Pair 2:			Upload score report
	Language Pair 3:			Upload score report
	Language Pair 4:			Upload score report

Language Proficiency

CAL SOPI or ACTFL OPI or ILR Test Taken:		Other Oral Proficiency Test Taken:
(required)		(required)
Language 1: Date Score Upload score report		Test name, date, and score: Upload score report
Language 2: Date Score Upload score report		Test name, date, and score: Upload score report
Language 3: Date Score Upload score report		Test name, date, and score: Upload score report
Language 4: Date Score Upload score report		Test name, date, and score: Upload score report

Self-reported Language Proficiency (optional)

Language Proficiency	Language History (check all that apply)	Reading	Writing
Language 1: English (required) Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None
Language 2: (required) Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None
Language 3: Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None
Language 4: Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None
Language 5: Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None
Language 6: Native Near-native Conversational	First language Primary School Primary Language of Instruction Secondary School Primary Language of Instruction Post-secondary School Primary Language of Instruction Community Language Studied as a subject in school Other	Fluent Basic None	Fluent Basic None

Availability (optional)

Not available Available
	Full-time Part-time On-call Contractor/free-lancer Volunteer	Days Evenings Nights Weekends	In-person Telephone Video

I am willing to travel miles from location.

I am willing to travel to the following regions: (check all that apply)
Region 1: Northwest District Kittson, Roseau, Lake of the Woods, Marshall, Beltrami, Pennington, Red Lake, Polk, Clearwater, Norman, Becker, Hubbard, Mahnomen	Region 2: Northeast District: Koochiching, Itasca, St. Louis, Aitkin, Carlton, Lake, Cook
Region 3: West Central District: Clay, Wilkin, Otter Tail, Grant, Douglas, Traverse, Stevens, Pope	Region 4: Central District: Cass, Crow Wing, Wadena, Todd, Morrison, Stearns, Benton, Wright Sherburne, Mille Lacs, Kanabec, Isanti, Pine, Chisago	Region 5: Metro Area: Anoka, Washington, Ramsey, Hennepin, Carver, Scott, Dakota
Region 6: Southwest District: Big Stone, Swift, Chippewa, Kandiyohi, Lac Qui Parle, Lincoln, Lyon, Yellow Medicine, Renville, Redwood, Pipestone, Murray, Cottonwood, Rock, Nobles, Jackson	Region 7: South Central District: Meeker, McLeod, Sibley, Nicollet, Le Sueur, Brown, Blue Earth, Watonwan, Waseca, Martin, Faribault	Region 8: South East District: Goodhue, Rice, Steele, Wabasha, Olmsted, Dodge, Winona, Freeborn, Mower, Fillmore, Houston

Subject/Specialty Areas (optional)

1000+ encounters in a variety of settings

-or-

Allergy/Asthma 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Audiology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Behavioral Health Counseling 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Cardiology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Chemical Dependency 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Critical Care/ER 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Dentistry 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Dermatology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Dialysis/Nephrology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Domestic Violence 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Endocrinology/Diabetes Care 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Family Practice 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Gastroenterology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Genetic Counseling 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Group health education 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Group therapy 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Home Health Care 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Hospice 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Infectious Disease/HIV/AIDS 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Internal Medicine 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Neurology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Neuro-psychology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Obstetrics and Gynocology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Oncology/Breast Cancer 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Ophthamology/Optometry 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Orthopedics 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Otolaryngology (ENT) 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Pediatrics 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Psychiatry 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Psychology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters
Pulmonology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Rehab Therapies 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Surgery 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Transplant 100+ encounters 20-99 encounters 1-19 encounters 0 encounters	Urology 100+ encounters 20-99 encounters 1-19 encounters 0 encounters

Formal Education/Training

I have a in Interpreting from .

I specialized in: (Check all that apply)

business interpreting conference interpreting educational interpreting legal interpreting
medical interpreting military interpreting police interpreting social service interpreting
other

	Area of Study	Degree Earned	School and Country	Years Attended	Language of Instruction
Secondary/High School				from to
Secondary/High School				from to
2-year College				from to
2-year College				from to
4-year College				from to
4-year College				from to
Graduate School				from to
Graduate School				from to
Program Certificates				from to
Program Certificates				from to
Licenses:

Professional Development and Individual Courses (Optional) (This section is neither accurate nor complete.)

Check any of the following courses that you have taken:

U of M Trin 3001 Introduction to Interpreting (45 hrs, 3 sem cr)	U of M Trin 3002 Consecutive Interpreting (45 hrs, 3 sem cr)	U of M TRIN 3004 Simultaneous Interpreting (45 hrs, 3 sem cr)
U of M Medical Terminology (45 hrs, 3 sem cr)
Bridging the Gap (40 hours)	IIMN Orientation to Interpreting (24 hrs)	Century College Orientation to Interpreting (24 hrs)
MN State Court Ethics Training (8 hrs)	MN State Court Orientation to Interpreting (16 hrs)	MN State Court Advanced Interpreting Skills Course

List any courses of 40 hours or more that you have taken (Name, date, number of hours, location, topic, sponsoring organization):

List any courses of 20 hours or more that you have taken (Name, date, number of hours, location, topic, sponsoring orgnization):

List any conferences or workshops you have attended (Name, date, number of hours, location, sponsoring organization):

Employer(s) (Optional)

Name	Address	Hrs/Wk	Dates Employed
			from month year to month year
			from month year to month year
			from month year to month year
			from month year to month year
			from month year to month year
			from month year to month year

Language Agency and Network Contracts This section may become a check all that apply section.

Please list your current agency affiliations:

Adangme	Adere see Harari	Afar	Afghan
Afrikaans	Akan/Twi	Albanian	Amharic/Ethiopian see Top 20 List
Amzgo/Guerrero	Anaang	Anuak see Top 20 List
Arabic	Arabic-Standard see Top 20 List	Arabic-Sudanese see Top 20 List
Arawak	Armenian	Asante see Akan

Bahasa-Indonesia	Bahasa-Malaysia see Malay	Bandi/Gbandi	Bari (Sudan)
Basaa (Cameroon)	Bassa (Liberia)	Behdini	Belarusan/Belorussian
Bengali	Berber see Tachelhit	Bhojpuri	Bhutanese
Please note that the Bhutanese refugees resettled in MN in 2008 primarily speak Nepali, not Bhutanese.
Bohemian see Czech	Bosnian see Top 20 List	Bruhui	Bulgarian
Burmese

Cakchiquel see Kaqchikel	Cambodian see Top 20 List	Cantonese	Caribe see Garifuna
Catalan-Valencian-Balear	Cebuano/Visayan	Cham, Western	Chatino, Nopala
Chatino	Chhatisgarhi	Chinantec	Chinese, Hakka see Hakka
Chinese, Mandarin see Top 20 List	Chinese, Min Nan see Taiwanese	Chinese, Yue see Cantonese	Chippewa see Ojibwe
Chochotec	Chol	Chontal	Chuukese
Creole see note below	Cuicatec, Tepeuxila	Cutchi	Czech/Bohemian
Please note: Creole denotes a variety of languages. Some languages it may denote include: Cutchi, Haitian Creole, Krio (Sierre Leone), Sango, Kituba, Arabic-Sudanese, Petjo, Negerhollands, Skepi Creole Dutch, Jamaican Creole, Sranan, Gullah, and Tok Pisin.

Dakota/Sioux/Santee	Dan see Gio	Danish	Dari/Farsi, Eastern
Dinka see Top 20 List	Dutch	Dzongkha see Bhutanese

Ebon see Marshallese	Edo-Benin	Efik	English
English Creole see note below	Esan-Anwain	Estonian	Ethiopian see Amharic
Ewe
Please note: English Creole and English Pidgin denote a variety of languages. Some languages they may denote include: Garifuna, Krio (Sierre Leone), Krio (Liberia), Jamaican Creole, Guyanese Creole English, Gullah/Geechee, Pidgin-Nigerian, Pidgin-Cameroon, Sranan, Islander Creole, Bislama, Hawai'i Creole English, Ngatik, Kriol, Pijin, and Tok Pisin.

Fante see Akan	Farsi, Eastern see Dari	Farsi, Western see Persian	Filipino
Finnish	Flemish	French
Fulfulde	Fulfulde, Adamawa see Sanyo

Ga	Gaelic, Irish	Gaelic, Scottish	Gallinya
Ganda/Luganda	Garifuna	Gband see Bandi	Gbe see Ewe
Georgian	German	Gikuyu	Gio/Dan/Yacouba/Yakuba
Goan/Goanese/Konkani	Grebo	Greek	Guerrero see Amzgo
Gujarati

Haaka	Haitian Creole	Harar	Harari/Adere
Hausa	Hawaiian	Hebrew	Hindi
Hmong see Top 20 List	Hokkien/Teochew	Huarijio	Huave
Hungarian

Ibibio	Ibilo	Ibo/Igbo	Icelandic
Igbo see Ibo	Indonesian-Bahasa see Bahasa-Indonesian	Italian

Japanese

Kachchi	Kahlkia see Mongolian	Kalenjin	Kanarese see Kannada
Kannada/Kanarese	Kaqchikel	Karen see Top 20 List	Karen, S'gaw
Kete	Kazakh	Khaskura see Nepali	Khmer/Cambodian see Top 20 List
Khmer Lue	K'iche'	Kirghiz	Kisi (Kena)
Kisi, Southern (Liberia)	Kissi, Northern (Guinea)	Kiswahili see Swahili	Kituba
Klao see Kru	Klaoh see Kru	Klau see Kru	Konkani/Konkanese
Konkani, Goanese see Goan	Konya see Maninka	Konyanka see Maninka	Korean see Top 20 List
Kosraean	Kpelle, Guinea	Kpelle, Liberia	Krahn, Western
Krepe see Ewe	Krio (Liberia) may refer to either Liberian English or Krio (Sierre Leone)	Krio (Sierra Leone)	Kroo see Kru
Kru/Kroo/Klao/Klaoh/Klau	Kru/Kumen-Tepo	Krumen-Teop see Kru	Kuku
Kunama	Kurdish	Kurdish, Northwestern see Behdini

Lahu	Lakota	Lao/Laotian see Top 20 List	Latvian
Lebanese	Liberian English	Lingala	Lingao
Lithuanian	Luba-Kasai see Tshiluba	Luba-Katanga	Lue
Luganda see Ganda	Luo

Maay, Somali see Somali-Maay	Magyar see Hungarian	Malay	Malayalam
Mam	Mandarin see Top 20 List	Mandingo	Mandinka see Mandingo
Maninka/Konya/Konyanka	Mano/Mawe	Marathi	Marshallese/Ebon
Mawe see Mano	Mazatec	Mende	Meta
Mien	Min Nan see Taiwanese	Mina (Camaroon)	Mina (India)
Mixe, Totontepec	Mixtec	Moldovan see Romaninan	Mong see Hmong, Green
Mongolian/Kahlkia	Morisyen	Murele

Nahuatl	Nepali	Norwegian	Nuer see Top 20 List

Ojibwe/Chippewa	Oromiffa see Top 20 List	Oromo, Borana-Arsi-Guji see Gallinya	Oromo-Eastern see Harar
Oromo-West Central see Oromiffa	Ossetian/Osetin	Otomi

Pahari, Eastern see Nepali	Pashto, Central	Persian/Farsi, Western	Pidgin, Cameroon
Please note: Patois denotes a variety of languages. Some languages it may denote include: Krio (Sierre Leone), Haitian Creole, and Tayo.
Pidgin, Nigerian	Polish see Top 20 List	Popo see Ewe	Portuguese
Poqomam	Pulaar	Pular	Punjabi, Eastern/Punjabi
Punjabi, Western/Lahndi

Quechua	Quiche see K'iche'	Quichua	Quottu see Harar

Romanian	Rundi	Russian see Top 20 List	Rwanda

Samoan	Sango	Santee Sisseton see Dakota	Sanyo
Sapo/Southern Krahn/Sarpo	Sarpo see Sapo	Serbo-Croatian	S'gaw see Karen-S'gaw
Shan	Shilluk	Shona	Sidamo
Sindhi	Singhalese see Sinhala	Sinhala/Singhalese/Sinhalese	Sinhalese see Sinhala
Sioux see Dakota	Slabonian see Slavonian	Slavonian/Slabonian/Slovene	Slovak/Slovakian
Slovene see Slavonian	Somali see Top 20 List	Somali-Maay	Soninke
Somali-Bantu refers to an ethnic group which speaks various languages including various Bantu languages. Somali-Maay is alternatively listed as a separate language or as a dialect of Somali. In any case it is not mutually intelligible with Somali.
Southern Krahn see Sapo	Spanish see Top 20 List	Susu	Swahili/Kiswashili
Swedish

Tachelhit/Berber	Tagalog see Filipino	Tamil	Tarahumara, Central
Tajik/Tajiki	Telugu	Teochew see Hokkien	Tepo see Kru
Thai	Themne/Temne	Tibetan	Tigre
Tigrinya see Top 20 List	Tlapanec, Acatepec	Tlapanec, Malinaltepec	Tojolabal
Totonac	Tshiluba	Turkish	Twi see Akan
Tzeltal	Tz'utujil/Tzutuhil

Ukranian	Urdu	Urhobo	Uzbek

Vai	Valencian see Catalan	Vietnamese see Top 20 List	Visayan see Cebuano

Wolof

Yacouba see Gio	Yakuba see Gio	Yao see Mien	Yiddish
Yoruba	Yue see Cantonese

Zapotec
			Other