Interpreter Services Statement Form printable pdf download

COUNTY OF LOS ANGELES

DEPARTMENT OF PUBLIC SOCIAL SERVICES

Interpreter Services Statement

(Please read script on the reverse side of this form to applicant/participant prior to completing)

CASE NAME: ___________________________

CASE NUMBER: ______________________

I, ____________________________________ am able to communicate in ____________________________.

(Specify Language)

I have been informed by the Department of Public Social Services (DPSS) that I have the right to a free

interpreter. If I want, I also have the right to use my own interpreter.

However, I know there may be

communication errors in using my own interpreter. This could result in problems such as loss of benefits

and/or eligibility.

I want to use a free County Certified interpreter.

I want to use my own interpreter even though I can get a free interpreter from DPSS. I know that there

may be problems of miscommunication by using my own interpreter. I know that sensitive information

could be discussed during the interpretation. However, I give permission to my interpreter by the name

of________________________________ to hear and interpret this information. My choice to use

my own interpreter is good for today only. I know that for future appointments, I have the right

to a free interpreter from DPSS.

__________________________

____________

Applicant’s/Participant’s Signature

DATE

Interpreter Confidentiality Agreement

I, _________________________________ am a County Certified Bilingual ___________________________

(Employee’s Name)

( Specify Language)

Interpreter. I understand that by law the information obtained during the process of interpretation

must be kept confidential and may not be disclosed outside of that process.

I, ____________________________________ speak both English and ______________________________.

(Interpreter’s Name)

(Specify Language)

I agree to keep this information confidential and not to disclose it, other than as required for interpretation.

My relationship to __________________________________ is _____________________.

(Applicant’s/Participant’s Name)

(Relationship)

______________________

___________

Interpreter’s Signature

DATE

FILING INSTRUCTIONS:

BWS/BSO - Documentation/Activity Folder

PA 481-A

Retention: Permanent

Interpreter Services Statement Form

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