1) Name and Address:

Name:        *
Address:    *
Address2:
City:           *
State:                 ZIP:  
Phone:            FAX:  

Email:        

2) Your occupation: 
(please click on the button beside the closest answer 
or fill out the "Other" category!) 

Interpreter      Manager   Physician     Nurse
Administrator   Other Health Professional Trainer or Educator
Health Interpreter Advocate  Health Technologist
Other  - Please Specify

If you are an interpreter:  Please tell us the languages you interpret?
(Please include all that you feel competent to interpret:) 
 

Please tell us something about yourself:

(WHEN YOU CLICK ON THE FIELDS BELOW A 'DROP-DOWN' SET OF CHOICES APPEARS. 
PLEASE SELECT FROM THE AVAILABLE CHOICES FOR QUESTIONS 3-8)
3. Please tell us your Gender: male female *

4. Tell us how long you have been interpreting: I am not an interpreter Less than a year 1-2 years 2-3 years 3-5 years 5-10 years More than 10 years! *

5. Do you interpret in healthcare settings? I am not an interpreter I do not interpret in healthcare settings. Less than a year 1-2 years 3-5 years 5-10 years More than 10 years *

6.  How often do you interpret in healthcare settings? I am not a healthcare interpreter I don't interpret in healthcare settings. Occasionally, about once a month Frequently, at least once a week (2-4 hours/week) About 3/4 times per week (8-10 hours/week) Daily (15-20 hours/week) Full-time professional (30-40+ hours/week)

7.  Have you had any previous training in healthcare interpreting? Not applicable - I am not an interpreter. No, not yet! Orientation of an hour or two plus reading ½ day orientation on the job 1 day program 2 day program 5 day (40 hour) training College Program (more than 40 hours) Graduate program

 8.  Are you a CHIA member? Yes, I am a CHIA Member I am not a member, but tell me more about membership! I am not a CHIA Member  

9. Enter any comments you may have in the space provided below: