To Whom It May Concern s15

COMMONWEALTH of VIRGINIA

Ronald L. Lanier Department for the Deaf and Hard of Hearing (804)662-9502 V/TTY Director RATCLIFFE BUILDING, SUITE 203 1-800-552-7917 V/TTY 1602 ROLLING HILLS DRIVE RICHMOND, VIRGINIA 23229-5012

To Whom It May Concern:

The enclosed Interpreter Request Form has been developed for Virginia Commonwealth agencies under contract with VDDHH for Interpreter Services. This form is designed for you to use when requesting sign language interpreters through the Virginia Department for the Deaf and Hard of Hearing (VDDHH). I hope it will make the interpreter request process as effortless as possible for you. When filling out the form, please provide as much detailed information as possible. The information is provided only to the interpreter(s) assigned to that particular assignment. The more information I can pass on to the interpreters, the better prepared they are for the assignment. Upon completion of the Interpreter Request Form, please fax it to the VDDHH office at 804-662-9796. As soon as an Interpreter is assigned to your event/meeting/appointment, I will call or fax the name of the interpreter(s) to the contact person indicated on the request form. If you need to inquire or provide additional information about a particular request, please call me at 1-800-552-7917 V/TTY or 804-662-9793 V/TTY. If you have an “emergency” interpreter request after normal business hours, please refer to the Directory of Qualified Interpreters for the Deaf and Hard of Hearing on our website (www.vddhh.org). The directory includes contact information for dozens of interpreters across the state. Feel free to contact these interpreters directly to discuss their availability, rates and qualifications. I hope this information is helpful to you. Please do not hesitate to call me if you have any questions, concerns or suggestions regarding any aspect of the Interpreter Programs.

Sincerely,

Erika M. Rockwell Interpreter Services Coordinator

FOR FAX PURPOSES ONLY. Complete and fax this form to VDDHH Interpreter Programs at 804-662-9796. SIGN LANGUAGE INTERPRETER REQUEST FORM VA DEPARTMENT FOR THE DEAF AND HARD OF HEARING RATCLIFFE BUILDING, SUITE 203 1602 ROLLING HILLS DRIVE RICHMOND, VA 23229-5012 1-800-552-7917 V/TTY 804-662-9502 V/TTY

TO: VDDHH Interpreter Service Program

DATE:______

Name of State Agency/Division:______

Contact Person:______Phone #______

Fax # or E-mail Address: ______------Date of Assignment:______Start Time:______Approx. End Time: ______

Names of ALL parties needing interpreter services (use additional form if necessary):

 We will not know in advance whether or not deaf persons plan to attend (i.e. meeting open to the public)  Deaf persons may/will attend, but their names are not yet known (i.e. conference requiring registration)  The following deaf person(s) will attend:

Deaf/HoH Person:______AGE___Gender___ Will this person be presenting? __ Yes __ No

Hearing Participants/Speakers (Please Specify Involvement):______

Type of Event/Meeting:______

______

Specific Details of Event/Meeting:______

______

Specific Location/Address of Assignment:______

______

Does your agency need an eVA-registered Interpreter (for billing purposes)? ___ Yes ___ No ___ Don’t Know

Billing Information: Agency:______

Billing Contact Person:______Address:______

City, State, Zip:______

FOR FAX PURPOSES ONLY. Complete and fax this form to VDDHH Interpreter Programs at 804-662-9796.

SIGN LANGUAGE INTERPRETER REQUEST FORM VA DEPARTMENT FOR THE DEAF AND HARD OF HEARING RATCLIFFE BUILDING, SUITE 203 1602 ROLLING HILLS DRIVE RICHMOND, VA 23229-5012 1-800-552-7917 V/TTY 804-662-9502 V/TTY

TO: VDDHH Interpreter Service Program

DATE:______

Name of Requesting State Agency/Division:___Complete name of agency______

Contact Person:_Name of person making request______Phone #__In case more information is needed____

Fax # or E-mail Address: __Must have to confirm services in writing______------Date of Assignment:__Date of meeting/event___ Start Time:______Approx. End Time: _estimated_

Names of ALL parties needing interpreter services (use additional form if necessary):

 We will not know in advance whether or not deaf persons plan to attend (i.e. meeting open to the public)  Deaf persons may/will attend, but their names are not yet known (i.e. conference requiring registration)  The following deaf person(s) will attend:

Deaf/HoH Person:_Complete names, ages & genders help us assign appropriate interpreters. AGE___Gender___ Will this person be presenting? __ Yes __ No

Deaf/HoH Person:_Please indicate whether each deaf attendee will be a presenter, if applicable.AGE___Gender___ Will this person be presenting? __ Yes __ No

Hearing Participants/Speakers (Please Specify Involvement):__Knowing the number/names of deaf participants/presenters and the number/names of hearing participants/presenters helps us understand the dynamics of the event/meeting and determine the appropriate number of interpreters for the assignment. ______

Type of Event/Meeting:__Important information for interpreters to determine whether or not they are comfortable accepting the job.______

Specific Details of Event/Meeting:_Details help the interpreters know what type of environment or situation they will be expected to handle. ______

Specific Location/Address of Assignment:__Please provide a complete address including zip code and room number, when possible. Interpreters may need this information to get directions to the assignment.______

Does your agency need an eVA-registered Interpreter (for billing purposes)? ___ Yes ___ No Billing Information: Agency:___A complete billing address is required for a request to be processed. Interpreters will bill your ______

Billing Contact Person:__ agency directly for their services and need complete and accurate billing ______

Address:__ information to do so. ______

City, State, Zip:______