Center of Health Disparities - Adventist HealthCare | Maryland
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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