Center of Health Disparities - Adventist HealthCare



Center for Health Equity & Wellness

|Qualified Bilingual Staff (QBS) Application Form (Please Print) |

|Note: Incomplete applications will delay processing and entry into class. |Today’s Date: November 3, 2016 |

|General Applicant INFORMATION |

|Last Name:     |First Name:       |Middle Name:       | Ms. | Dr. |Hospital/Org: |

| | | |Mr. |Mrs. | |

| | | | | | |

|Course Dates & |March 22, 23 & 24 2017 | |

|Location: |Maryland Hospital Association | |

| |Room Pierson Conference Center | |

| |6820 Deerpath Road | |

| |Elkridge, MD 21075 | |

| |Cost: $360 per person (covers 3 day training, meals, and testing). The QBS program was developed to train and certify bilingual staff on proper |

| |interpreting skills during a medical encounter. |

|Please complete ALL of the information below: |

|Home Address:       |Apt. #:       |Sex: M F |

|City:       |State:       |ZIP Code:       |

|Work Phone: (   )     –      |Home Phone: (   )     –      |Cellular Phone: (   )     –      |

|E-mail Address:       |Department:       |Job Title:       |

|Please note: Your email address will only be used for important communications regarding the QBS program. |

|Manager/Supervisor:       |Manager/Supervisor’s Email:       |

|Manager/Supervisor Phone Number: (   )     –      |Your Country of Birth:       |Ethnicity: |

|Certification is available in the following languages: |Ethnicity: (Hispanic/Latino, or specify other): |

| |Race: (Select all that apply.) |

|Amharic, Arabic, Armenian, Cantonese, Farsi, French, Japanese, Khmer, Korean, Mandarin, |Black or African American Asian |

|Portuguese, Russian, Spanish, Tagalog, Vietnamese |American Indian or Alaskan Native White |

| |Native Hawaiian or Other Pacific Islander |

| |Two or More Races (please specify)       |

|Please note: We must have at least 2 speakers of any given language in the class. | |

|Program INFORMATION |

| |How did you hear about this program?       |

| |What is your native language?       |3. |What additional language(s) are you proficient in?       |

| |Where did you learn your second language?       |

| |On average, how many times a week are you asked to interpret for a limited English proficient patient?       |

| |Please state why you are interested in this course.       |

|I certify that the information contained on this form is accurate and complete to the best of my knowledge. |

|Applicant Signature:       |Date:       |

|MANAGER APPROVAL |

|Please accept my signature as approval for the above candidate to participate in the Qualified Bilingual Staff Program. I am aware that participation includes compliance |

|with program guidelines: |

|Managers will incorporate the 3-day required attendance (24-hour training) into the candidate’s regular scheduled hours. |

|Candidates are allowed hours for course dates and a 1 hour language proficiency assessment to achieve full certification. (This applies to full-time and regular part-time |

|employees who work 20+ hours per week only. Manager discretion is required for limited part-time employees.) |

|Manager Signature:       |Date:       |

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