DHCC Employee Interpreter Request

For DHCC employees to request for DHCC, VSC, and CIP

Are you requesting an ASL Interpreter as...

DHCC

Victim Services Center (VSC)

Community Interpreting Program - Family Gathering, Wedding, Funeral, Etc.

Other

Requester Contact Information

Name of employee completing this form

First name

Last name

Email of employee completing this form

Phone number of employee completing this form

Is your phone number a voice or videophone number?

Voice

Videophone

Other

Assignment Details

Communication Mode Options

ASL Onsite

ASL Video Interpreting

CART

Date of Service

Interpreter Arrival Time

Time

HoursMinutes

Interpreter Start Time

Time

HoursMinutes

Interpreter End Time

Time

HoursMinutes

Contact Person for Day of Service

First name

Last name

Contact Phone Number

Street Address / Location / Building Name/ Where to check in

Please enter the address where the interpreting assignment will take place. If this is a remote interpreting request, please enter "Remote" under Street Address and City then select "Pennsylvania" for State and enter your zip code.

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Location / Building / Business Name

Additional Location Info

Security, Parking, etc.

Assignment Description

Deaf/Hard-of-Hearing Client Name

First name

Last name

Will Deaf / Hard-of-Hearing clients be in attendance?

Yes

No

Other

Description of Assignment

This includes reason of the request, including any other attendees and their roles

Additional Information

Any information that would be helpful for ASL Interpreter for day of service.

Name(s) of Requested Interpreter(s)

Will this be recorded and used for promotional material, printed articles and/or video? Will it be shared with other individuals or entities not present during filming?

Yes

No

DHCC Employee Interpreter Request

Requester Contact Information

Assignment Details

Assignment Description

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