Please check one of the following:*

New Interpreter
New Release Form
Changes on Current Information

Personal Information

Today's Date:* (month/day/year)

Legal Name: *

Business Name:

RID Membership Number (optional):

Mailing Address: *

City: *

State: *

Zip Code:* (include the four number extension)

Primary Contact Phone Number:* (include area code)

This phone number is a

Home Work Cell Pager number

Secondary Contact Phone Number: (include area code)

This phone number is a

Home Work Cell Pager number

Fax Number: (include area code)

E-mail Address:*

List Your Qualifications:
NIC Master
NIC Advanced
NIC

RID

Check your level for RID:

CI CT CSC

NAD Interpreter Proficiency Card/Certificate

Check your level for NAD:

Level III Level IV Level V

Mid-America Quality Assurance Screening Test (QAST) - Interpreting

Check your level for QAST Interpreting:

Level I Level II Level III Level IV Level V

Mid-America Quality Assurance Screening Test (QAST) - Transliterating

Check your level for QAST Transliterating:

Level I Level II Level III Level IV Level V

If this is your first time signing a
release form please arrange a meeting with the Interpreter Program Coordinator to discuss
NCDHH's Referral Policies and Procedures and bring a current copy of your current screening card of certification.

Print off and sign the below release form and return it to the Nebraska Commission for the Deaf and Hard of Hearing office.

Interpreter Referral Release Form*
*Acrobat Reader is necessary to view this files. Download a free version here.

Interpreter Information

Please list any changes to your professional status:

List the type of assignments you will not accept:*
Legal Medical Educational Mental Health
Other
Describe what you mean by other:

Describe what geographical areas you will be available for:*

Lincoln Metro Area Omaha Metro Area Central Nebraska Western Nebraska

List the time frames that you are not available to accept interpreting assignments from the Statewide Sign Language Interpreter Referral Service.*

The times that you list as not available, you will not be called for assignments during that time span. To make changes in these times you will need to contact the Referral Service. It is suggested that interpreters periodically call the Referral Service to check on the times that the interpreter is marked out of service.