P.O. Box 6134
Tyler, TX 75711-6134
Application for Interpreter/Independent Contractor Service
Tyler Deaf and Hard of Hearing Center ("TDHHC") is committed to providing equal opportunity to all independent contractor applicants regardless of race, religion, color, sex, age, national origin, disability, citizenship status, military status, or any other characteristic protected by law. Applicants requesting reasonable accommodation to the application and/or interview process should notify the TDHH Communication Coordinator at (903) 617-6204.
Name: Address:
Date of Birth: Email:
Cell: Phone:
Business Name (if applicable): Type of Business (check one):
Sole Proprietor Corporation Partnership Limited Liability Company Other:
Federal ID (EIN) Number (if business):
Have you or your company obtained all applicable licenses and/or certificates necessary to do business as an independent contractor or a self-employed person? Yes No
Have you obtained all applicable professional licenses and/or certificates required to provide sign language interpretation services? Yes No
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As part of the application process, certified applicants that hold BEI Basic, Level I, or the NIC will be required to show a sample of their work both expressively and receptively in person.
Professional Organization active membership(s):
Education:
Name and City of School Attended From To Degrees Earned Month/Year Month/Year Month/Year
Prior Work Experience: Please complete this section regarding your current and prior employment and/or independent contractor engagements, starting with your most recent position. Include periods of unemployment and explain any gaps.
Company Dates Describe the work,
responsibilities, and services:
Telephone
From To Address
Job Title (if applicable)
Name and Title of Last Supervisor (if applicable) Base Salary or Service Fees
$
Reason for Separation
Company Dates Describe the work,
responsibility, and services: Telephone
Address
Final Job Title (if applicable)
Name and Title of Last Supervisor (if applicable) Base Salary or Service Fees $
Reason for Separation
Company Dates Employed Describe the work, responsibilities, and services:
Telephone
From To Address
Final Job Title (if applicable)
Name and Title of Last Supervisor (if applicable) Base Salary or Service Fees $
Reason for Separation
May we contact these companies concerning this application? Yes No If no, explain:
Describe Specific Interpreting Experience:
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Interests (Hobbies):
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Are you currently under indictment for, or have you ever pled guilty, no contest, or been offered deferred adjudication or convicted of, a felony or misdemeanor by a civilian or military court? Please list misdemeanor convictions within the past three (3) years and felony convictions within the past seven (7) years. You may exclude minor traffic violations. Answering yes to a conviction of a crime will not automatically disqualify you
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from an independent contractor status. All relevant factors will be considered, such as the seriousness of the offense, when it occurred, and how it relates to the position. Yes No
If yes, provide complete details, including the nature of the crime, the date and place of conviction, the date and place of incarceration, if any, and disposition, including any suspended sentence, fines, probation, deferred adjudication, or similar disposition (attach additional pages if necessary):
Do you have transportation to get to and from work? Yes No Do you have a valid Driver’s License? Yes No
If yes, provide: State: License #:
Do you have liability insurance on your vehicle? Yes No
If yes, please provide policy information (including name of insurance company, policy number, policy limits, and effective date):
Do you or your company have employees? Yes No
Do you or your company have professional liability insurance coverage (E&O)? Yes No
If yes, please provide policy information (including name of insurance company, policy number, policy limits, and effective date) and by signing below you acknowledge and agree that if engaged as an independent contractor by TDHHC you will be required to maintain your own professional liability insurance coverage (E&O) while working as an independent contractor with TDHHC.
If engaged by TDHHC as an independent contractor, you will be required to ensure that you and all of your employees are eligible to work in the U.S. and shall be solely responsible for complying with the Immigration Reform and Control Act.
Are you and your employees, if any, legally authorized to work in the U.S.? Yes No
If engaged by TDHHC as an independent contractor, do you understand that you shall be solely responsible for paying when due all self-employment, income, and other taxes incurred as a result of services fees
paid by TDHHC to you? Yes No
Were you previously employed by, or have you ever provided interpreter services on behalf of TDHHC? Yes No If yes, provide date(s):
Would you like to work Emergency ON-Call? (Requirements: TX: Level III, IV, V, Advanced, Master. RID: CI/CT, Advanced, Master. NAD: IV, V) Yes No
Can you work evenings/weekends? Yes No Are there any days that you are not available? Yes No
List days and times you are unavailable: _________________________________________________________ __________________________________________________________________________________________ Please list any type of assignment request that you would refuse to do.
1. 2. 3. 4. 5.
How far are you willing to travel from your home? (Miles/minutes/hours)
Please list any area or city that you are not willing to travel:
REQUIREMENTS
Please provide (i) three references (one of which must include a reference from a former employer); (ii) a current résumé; and (iii) the completed application, including all Appendices attached hereto and incorporated herein for all purposes; (iv) a copy of all current certifications (State and/or National); (v) a copy of current certificate of liability insurance (E&O); (vi) a copy of certificate of completion for HIPAA training; (vi) a copy of driver’s license; (vii) completed W-9 form. If you attended/graduated from an Interpreter Training Program within the past five (5) years, we will be contacting the director of that program for an additional reference. List the name, relationship, and contact information for an emergency contact:
ACKNOWLEDGMENTS
If engaged by TDHHC as an independent contractor, you understand and acknowledge that (1) you shall be solely responsible for supervising, controlling, and directing the details and manner of the completion of services provided; (2) TDHHC shall not have the right to hire, supervise, control, or direct the details and manner of the completion of the services provided; (3) the services provided must meet TDHHC’s final
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approval and shall be subject to TDHHC’s general right of inspection throughout the performance of the services to secure satisfactory final completion; (4) you would not be an agent of TDHHC and would not have any right or authority to bind, commit, or otherwise obligate TDHHC to any terms, conditions, or contractual obligations with any other party; (5) for all purposes, including but not limited to any laws concerning Social Security, disability insurance, unemployment compensation, workers’ compensation, tax withholding and payment, and all other federal, state, and local laws, rules, and regulations relating to employees, you and your equity holders, shareholders, members, managers, directors, officers, employees, agents, contractors, affiliates, or representatives (collectively, "Affiliates") shall be treated as a self-employed independent contractor of TDHHC; (6) you shall be solely responsible for complying with all obligations imposed upon you and your Affiliates as an independent contractor by all applicable federal, state, or local laws, rules, and regulations including but not limited to those relating to income taxes and the filing of all returns and reports, payment of all assessments, taxes, and other sums required by applicable law with respect to service fees paid by TDHHC (and further that, by signing this application, you agree to indemnify, defend, and hold TDHHC and its affiliates harmless against any claims or liabilities arising out of or related to your failure to comply with such obligations); (7) neither you nor your Affiliates shall be covered by TDHHC’s insurance policies (including without limitation workers’ compensation insurance) or eligible for employee benefits provided by TDHHC to its employees (and further that, by signing this application, you waive on behalf of yourself and your Affiliates any right to participate in such benefits programs); (8) you shall be solely responsible for the payment of your own income, self-employment, Social Security, and other applicable taxes and insurance premiums and the income, self-employment, Social Security, and other applicable taxes and insurance premiums of your Affiliates; (9) neither you nor your Affiliates will be entitled to unemployment compensation benefits from TDHHC if your engagement with TDHHC terminates; and (10) you shall be required to provide professional liability insurance policies and provide TDHHC with a copy of the insurance certificate as proof current insurance. You further understand and acknowledge that this document is not an application for employment, that TDHHC is not considering you for employment, and that nothing in this document guarantees any engagement as an independent contractor for any specific period of time.
CERTIFICATION
I certify that the statements I have made on this application and during the interview process are true and complete to the best of my knowledge. I understand that any false, incomplete, improperly omitted, or misleading statement made by me will disqualify me from being engaged by TDHHC as an independent contractor.
AUTHORIZATION AND RELEASE STATEMENT
I hereby authorize and direct TDHHC to make whatever inquiries and obtain whatever information it deems necessary in connection with my possible engagement as an independent contractor. I further authorize and direct my former employers, the director of any Interpreter Training Program that I attended, and other third parties to furnish TDHHC with all information they may have concerning me. In consideration of TDHHC’s undertaking to review this application and to consider me for engagement as an independent contractor, I release and acquit any person or entity supplying information to TDHHC, as well as TDHHC and its agents,
employees, officers, directors, owners, and affiliates, from any liability whatsoever, INCLUDING
LIABILITY RESULTING FROM THEIR NEGLIGENCE OR GROSS NEGLIGENCE, for any injury or
damage that I may suffer or sustain by reason of TDHHC’s acquisition or use of any such information.
Applicant’s Signature: Date:
A-1
Appendix A
Rate of Compensation
Description of Service Current HourlyRate
Proposed Hourly Rate
Agreed Hourly Rate
General Daytime Less than 24 hr Day Evening/Weekend Less than 24 hr Evening/Weekend
Overnight/Holiday/Emergency Legal Daytime
Less than 24 hr Legal Daytime Legal Evening/Weekend Less than 24 hr Legal Evening/Weekend
Legal Holiday/Emergency State CSSA Assignments
Cancellation Policy: Requests for Services cancelled with less than one (1) business day/24 hour notice will be billed for the full appointment. NOTE: All scheduled and confirmed appointments will be billed even if the deaf or hard of hearing client does not show up for their appointment.
Any incurred travel time which falls outside of the two hour minimum will be billed at appropriate stated rate.
Terms: Rates are not effective until signatures are completed by both parties.
We, the undersigned, agree to the amount(s) for compensation as listed in "Agreed Rate" of this form.
______________________________________________________________________________ Interpreter/Independent Contractor - Date TDHHC Representative - Date
______________________________________________________________________________ Interpreter's printed name Certification(s)
Appendix B
TDHHC Interpreting: Interpreter Self Evaluation Form
Please rate your competency in the following areas by placing a check mark in the boxes under the appropriate number. (1 = Poor; 5 = Excellent). Under "Settings," write "NO" in the comments section if you do not want to interpret in that setting.
Language & Interpretation Skills
1 2 3 4 5 Comments
English (written & spoken) American Sign Language Knowledge of Deaf Culture Knowledge of Interpretation Knowledge of Ethics
ASL-ENG Interpretation Skills ENG-ASL Interpretation Skills Team Interpreting
CDI Team Interpreting
Settings 1 2 3 4 5 Comments
Business Meetings Chemical Dependency Conferences/Conventions Cued Speech
Deaf/Blind (Tactile) Deaf/Blind (Low Vision) Educational Pre-school Educational K-12
Educational Post-Secondary Employment Situations High Profile
Legal Legislative Medical Mental Health Minimal Language On-Call Emergency Oral
Performing Arts
Religious (specify religion) Technical (i.e. computer)
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Appendix C
HIPAA AND HITECH ACKNOWLEDGEMENT FORM
1HIPAA AND HITECH Polices For
All TDHHC Employees and Independent Contractors
What is HIPAA?
Health Insurance Portability and Accountability Act of 1996 ("HIPAA").
Privacy and security rules for identifying, handling, using or disclosing protected health information ("PHI").
As a Business Associate of Covered Entities, and a contractor to certain government or municipalities, TDHHC must comply with certain provisions of HIPAA and HITECH.
All employees and independent contractors of TDHHC are required to abide by TDHHC policies regarding HIPAA and HITECH.
What is HITECH?
Health Information Technology for Economic and Clinical Health Act, Title XIII of the American Recovery and Reinvestment Act of 2009 ("HITECH").
New mandates extend privacy and security requirements previously applicable to Covered Entities, now to Business Associates, including TDHHC and its employees and independent contractors.
Business Associates now subject to the same civil and criminal penalties for violation as Covered Entities.
Administrative safeguards, technical safeguards and physical safeguards are required.
Documentation and appointment of a security official is required.
What is PHI?
PHI is individually identifiable health information, transmitted or maintained in any form or medium held by Covered Entities or their Business Associates:
o Can be in any form or medium, including oral;
o Relates to past, present or future physical or mental health or condition of any person;
o Includes information about provision of health care and payment for provision of health care; and
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o Identifies a person, either by name or by information that could be used to identify the person (SSN, address, relation to another named person, employer, DOB, email address, medical record number, fax, phone, driver's license, photos, etc.).
Examples of PHI
You may have access to PHI when texting, calling, emailing or making notes or collecting information for an assignment that includes:
An individual's name and medical procedure or condition;
An individual's name and name of medical facility, specialty or doctor;
An individual's email/IP address and medical procedure; and
An individual's email/IP address and name of doctor or condition. You may have access to PHI:
Prior to an assignment, while arranging the assignment, including telephone, text, email, fax or written notes;
During an assignment (even if not part of the communication process);
As a result of presence in medical facilities; and
In connection with invoicing, recordkeeping and billing.
Guidelines
TDHHC has established procedural guidelines to address the following six (6) areas to enforce the principle of "minimum necessary" use of information to accomplish purpose and/or service to the customer. The Security Rules shall include: Administrative Safeguards; Physical Safeguards; Technical Safeguards; Organization Requirements; Policies and Procedures; and Documentation Requirements. TDHHC will provide you with training on state and federal privacy and security requirements, customized to your responsibilities and types of contact with PHI, within sixty (60) days after your contract enforcement date, and once every two (2) years thereafter.
Administrative safeguards shall include, but are not limited to training, instruction to employees and independent contractors, and policies and procedures regarding the HIPAA Privacy Rule.
Technical safeguards shall include, but are not limited to computer passwords, timing out of screens, storing laptop computers in a secure location and encryption.
Physical safeguards shall include, but are not limited to locks on file cabinets, door locks, partitions, shredders and confidential information destruction.
C-3
TDHHC will require an annual review of the HIPAA Privacy Rule and internal policies and will review and modify any areas of concern at such time of the annual review or as a concern is identified, whichever event comes first.
Documentation Requirements shall include a comprehensive, step by step protocol to follow in the event a breach should occur.
Required Action if Breach or Possible Breach
If a breach, or possible breach, is discovered, TDHHC Management must be notified immediately.
TDHHC Management must collect information regarding the breach:
o Description of breach;
o Date of discovery of breach;
o Name of persons affected by breach;
o Types of PHI involved in the breach (i.e. name, SSN, DOB, address, account numbers, medical details, etc.); and
o Description of anything that has been done to investigate, mitigate loss or protect against further breach.
Discovery of Breach: Employee or independent must immediately notify TDHHC Management by telephone/videophone and email of the believed breach and documentation that led to this conclusion. If the incident occurs after business hours or on a weekend or holiday notification shall be provided by emailing the TDHHC Management immediately. TDHHC will take prompt corrective action to mitigate any risks or damages involved with the breach and will notify business contacts affected of such breach.
Investigation of Breach: TDHHC shall immediately investigate such security incident, breach or unauthorized use of confidential data. Within 72 hours of discovery (of the breach), TDHHC shall notify business contacts affected of such breach of the following:
a) What data was involved and the extent of the data in the breach;
b) A description of unauthorized persons known or reasonably believed to have improperly used or disclosed confidential data;
c) A description of where the confidential data is believed to have been improperly transmitted, sent or utilized; and
d) A description of probable causes of the improper use or disclosure.
Written Report: A written report shall be compiled within 10 days that shall include, but not be limited to the information specified above, an estimation of cost for remediation as well as a full detailed corrective action plan, including information on measures that were taken to halt and/or contain the improper use or disclosure. As the HIPAA and HITECH information is updated or modified, TDHHC will notify you of those changes.
ACKNOWLEDGEMENT OF RECEIPT AND REVIEW OF HIPAA AND HITECH POLICY
The undersigned acknowledges receipt of a copy or review of the HIPAA AND HITECH Polices For All TDHHC Employees and Independent Contractors.
The undersigned agrees to comply with the HIPAA AND HITECH Polices For All TDHHC Employees and Independent Contractors and acknowledges that compliance with such policy is required of all employees, independent contractors, and subcontractors performing services of TDHHC's behalf. The policy requires, among other things, training on state and federal privacy and security requirements and breach and disclosure reporting requirements.
The undersigned is encouraged to ask questions or request further information of TDHHC if there are questions regarding terms, obligations or compliance with the policy.
_______________________________________ Signature
_______________________________________ Printed Name
_______________________________________ Date
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Appendix D
NAD-RID CODE OF PROFESSIONAL CONDUCT
I, __________________________ (name), shall accept and perform or decline offered work according to fair business practice, sound professional judgment, and adherence to the National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf, Inc. (RID) ("NAD-RID") Code of Professional Conduct, including, but not limited to the following tenets:
1. Interpreters adhere to standards of confidential communication.
2. Interpreters possess the professional skills and knowledge required for the specific interpreting situation. 3. Interpreters conduct themselves in a manner appropriate to the specific interpreting situation.
4. Interpreters demonstrate respect for consumers.
5. Interpreters demonstrate respect for colleagues, interns, and students of the profession. 6. Interpreters maintain ethical business practices.
7. Interpreters engage in professional development.
A complete detailed explanation of tenets may be found at: http://www.rid.org/UserFiles/File/NAD_RID_ETHICS.pdf
___________________________________ Name
___________________________________ Printed Name
___________________________________ Date
