MCD10 Interpreter Application and Eval Form.pdf

MCD10 SIGN LANGUAGE INTERPRETER APPLICATION AND EVALUATION FORM

To Be Completed by Interpreter / Applicant and by MCDHH

Interpreters respond in unshaded cells. MCDHH responds in pale yellow cells. If additional space is needed, attach additional page(s). Contact lori.novak@mass.gov with questions.

I. NAME / ADDRESS / BASIC DATA: INTERPRETER COMPLETES:

Fill in All Sections

MCDHH COMPLETES:

Are All Sections Completed Accurately? Yes/No

NAME:

D/B/A (if applicable):

ADDRESS (Street / PO Box):

ADDRESS (City / Town / State / ZIP):

Email:

Phone / VP:

MMARS Vendor Code (“VC” plus ten digits):

COMMBUYS Registration Number (eight digits):

CORI Requested: [N/A] CORI requested from EHS;

When?

II. BASE RATE CALCULATION: [NA] MCDHH COMPLETES:

Refer to certification, years of certification (less any breaks in certification), and the current rate sheet [N/A]

Referring to information on this document plus the current rate sheet, determine the interpreter’s base hourly rate.

[N/A] Base hourly rate is: $

III. QUALIFICATION FOR MCD10 CONTRACT: [N/A] MCDHH COMPLETES:

Is this interpreter qualified to participate in Contract MCD10? [N/A]

Based on the information on this form, this interpreter is qualified to participate in Contract MCD10: Yes/No

IV. CERTIFICATION DOCUMENTATION AND

EXPLANATION:

INTERPRETER COMPLETES:

Self-Explanatory

MCDHH COMPLETES:

Verify documentation and note break in certification. Is this section complete?

Yes/No

Append screen print of RID/NAD or BEI page showing how long you have been certified or date of original certification.

Were there any breaks in your certification? Yes/No:

If YES, describe below.

V. CERTIFICATION / SCREENING TYPE: INTERPRETER COMPLETES:

Check Applicable Certification(s)

MCDHH COMPLETES:

Are Certification(s) Checked Accurately? Yes/No

RID/NAD Certified, Yes/No:

BEI Certified, Yes/No:

MCDHH State Screened (MCDHH Approved) , Level II, Yes/No:

MCDHH State Screened (MCDHH Approved) , Level I, Yes/No:

mailto:lori.novak@mass.gov

VI. YEARS CERTIFICATION: INTERPRETER COMPLETES:

Check Which Applies

MCDHH COMPLETES:

Is “Years Certification” Accurate? Yes/No

Date of original certification (RID/NAD or BEI):

RID/NAD or BEI Certified 0-4 years, Yes/No:

RID/NAD or BEI Certified 5-9 years, Yes/No:

RID/NAD or BEI Certified 10-14 years, Yes/No:

RID/NAD or BEI Certified 15-19 years, Yes/No:

RID/NAD or BEI Certified 20-24 years, Yes/No:

RID/NAD or BEI Certified 25-29 years, Yes/No:

RID/NAD or BEI Certified 30-34 years, Yes/No:

RID/NAD or BEI Certified 35-39 years, Yes/No:

RID/NAD or BEI Certified 40+ years, Yes/No:

VII. OTHER INFORMATION INTERPRETER COMPLETES:

Self-Explanatory

MCDHH COMPLETES:

Self-Explanatory

Have you ever been subject to action under an MCDHH Interpreter Contract (MCD01, MCD06, or other contract) Quality Assurance Program such as progressive sanctions, suspension, or termination? Yes/No:

If YES, describe below.

[Refer all application forms with information in this section to the Director, Communication Access Services.]

CORI Results CORI results; date.