Form Dss-10001 - Language Services Agreement - North Carolina
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1LANGUAGE SERVICES AGREEMENT
For Limited English Proficiency (LEP) Customer
And Sensory Impaired Customer
For Office Use Only
CUSTOMER: _________________________________________ DATE: _______________
AGENCY: _______________________________PROGRAM: ________________________
PROGRAM STAFF MEMBER: _________________________________________________
LANGUAGE SERVICE PROVIDED:
__ Foreign Language Interpreter
__ Sign Language Interpreter
__ Written Translation (list documents) __________________________________________
__ Foreign Language Telephonic Service (service name) ____________________________
__ Braille
__ TDD/TTY
__ Assistive Technology device for Sensory Impaired (type) __________________________
__ Large Print
CUSTOMER STATEMENT
I was offered the services of an interpreter/translator, at no cost to me, by the agency and
on the date shown above. I elect to:
__ accept the services of an interpreter/translator provided by the agency, or
__ prefer the use of an assistive technology device provided by the agency, or
__ decline the use of any interpreter/translator services and/or assistive technology device, or
__ provide my own interpreter/translator services or assistive technology device
(Name of provider or product: _____________________________________________)
I agree to provide information needed by the agency to assist me. I understand that this
information is confidential and will be used only for purposes of delivering services to me
.
Customer Name (print) _________________________________________________________
Customer Signature: ____________________________________ Date: ________________
INTERPRETER/TRANSLATOR STATEMENT
I, ___________________________, will accurately interpret the interview/conversation/
information of ________________________________ on ____________. I will accurately
relay any and all information to and from this customer. As required by G.S. 108A-80, I will
protect the confidentiality of all information regarding this customer.
Interpreter Name (print) ______________________________________________________
Interpreter Signature: ___________________________________ Date: ______________
If Interpreter services are provided by telephone, it will be in accordance with all agency and
contractual confidentiality requirements.
TO BE FILED IN CASE RECORD
DSS-10001 (06/05)
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