IC Interpreter Intake Form

1

Are you an American Sign Language interpreter or a Spoken Language Interpreter?If you are both, please select "ASL."

ASLSpoken Language

2

Who are you?* This field is required.Thank you for taking the time to fill out this form.

First Name (as shown on your income tax return)

Last Name (as shown on your income tax return)

Registered Business Name (if different from above)

Primary Email Address

Date you can start working

Primary Phone Number

Timezone

Gender

3

What languages are you qualified to interpret?* This field is required.Select all that apply.

4

Interpreting SpecialtiesPlease choose any applicable specialities from the dropdown.

5

Services TypesPlease select the type of jobs you would like to receive from the dropdown.

6

Professional Headshot* This field is required.Please upload a clear, professional looking headshot which we will upload into your personnel file.

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Max. file size: 10.6MB

7

Address* This field is required.Your primary address will be used to determine job offers based off your distance to the job-site.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

8

How did you learn about us?* This field is required.If you were referred to us by one of our employees or contractors, please use the Other option and let us know their name!

Social Media

Search Engine

Email Newsletter

Word of Mouth

In-Person Event or Tradeshow

Other

9

Partnering AgenciesPlease select which agencies that you are currently working with

Boostlingo

Corporate Translation Services

Globo

SignGlasses

LanguageLine

Deaf Services Unlimited

Heritage Interpreting

10

Tax Information and Direct DepositIf you are serious about applying to work with us and would like to expedite the onboarding process, click "Yes" to fill out tax information, including your SSN, and banking info. If you are merely interested in a position and still considering, please click "No."

YESNO

11

Birthday* This field is required.Used for background check purposes.

Date

12

Tax Information* This field is required.Check the appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited Liability Company (enter the tax classification below)

Other

13

Tax Information (2)

State in which business registration was filed

Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

List account number(s) here (optional)

14

Taxpayer Identification Number (TIN)* This field is required.Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number SSN However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number EIN If you do not have a number, see How to get a TIN, later.

Social Security Number

Employee Identification Number

15

Social Security Number* This field is required.

16

Employee Identification Number* This field is required.

17

Certification* This field is required.1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Acknowledgment: Under penalities of perjury, I certify the above statements are true.

18

Direct Deposit Information* This field is required.

Routing Number

Account Number

Financial Institution Name

Account Type

19

Independent Contractor Rates Preview* This field is required.The rates you enter here are a preview for us. You will need to finalize your rates when signing our contractual agreement later on. Note Regarding travel time: For on-site projects or "assignments," Contractor may submit travel time when closing their jobs as an "incidental" if the assignment took place outside of Contractor's city of residence.

Hourly Base Rate

Hourly Premium Rate (Holidays/Weekends/Overnight)

Legal Rate (If Applicable)

Other

20

Assignment Terms* This field is required.Hands Up Communications maintains the following terms for all Language Service Providers: 1. ASL: 2 Hour Minimum On-Site 2. ASL: 1 Hour Minimum Prescheduled VRI 3. Spoken: 1.5 Hour Minimum On-Site 4. Spoken: 1 Hour Minimum Prescheduled VRI 5. All Languages: Overages Paid in 15 Minute Increments 6. All Languages: After Hours Premium Rates Effective After Business Hours, which are 7:00 AM to 5:00 PM, Monday Through Friday of the Company's Time Zone 7. All Languages: One (1) Business Day Cancellation Policy for All Assignments 8. Direct Deposits Made 30 Days Out From the Assignment and Biweekly Thereafter

I agree to the above terms.

21

ASL Interpreters: Do you have an active certification via RID or BEI* This field is required.

YESNO

22

Please upload supporting documentation that clearly displays the expiration of your certification.

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Max. file size: 10.6MB

23

ASL Interpreters: Do you hold an EIPA certificate?* This field is required.Spoken Language interpreters: select "No"

YESNO

24

What is the score you received on your EIPA?

EIPA score

25

ASL Interpreters: Do you hold any state interpreting licenses?* This field is required.

YESNO

26

State License UploadPlease upload supporting documentation of your active state interpreting licenses.

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Max. file size: 10.6MB

If you do not hold any state interpreting licenses, please click Next.

27

Résumé* This field is required.Please upload a copy of your résumé (PDF only).

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Max. file size: 10.6MB

28

Would you like to upload any copies of HIPAA/FWA certificates that you have earned in the last two years?

YESNO

29

HIPAA TrainingYou can upload your own HIPAA Training Certificates

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Max. file size: 10.6MB

30

Fraud, Waste, and Abuse (FWA) TrainingYou can upload your own FWA Training Certificates

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Max. file size: 10.6MB

31

UnityPoint Compliance

All service providers with Hands Up Communications are expected to comply with the information presented in the following training materials. You may review the information below at a later time, but prior to rendering services for us.

No signatures are needed.

General Compliance training. You may view the CMS training module, available at Medicare Parts C and D General Compliance Training (cms.gov).

UnityPoint Health Code of Conduct, available at Code of Conduct.

UnityPoint Health Guidance for Business Partners, available at Guidance for Business Partners.

Model of Care slide deck provided by Aetna, available at Model of Care--Aetna.

You may also review the documents below, which can be found on the following page:

UnityPoint Health Corporate Compliance Program
Cultural Resource Guide
Gender Inclusive Language Guide
Glossary and Language Guide
UnityPoint Health Policy 1.CE.22, Use of Interpreters, Translators, and Auxiliary Aids for Individuals with Communication Barriers

32

UnityPoint DEI Terms GlossaryNo signature needed. For review only.

33

UnityPoint Gender Inclusive Language GuideNo signature needed. For review only.

34

UnityPoint Use of Interpreters, Translators, and Auxiliary Aids for Individuals with Communication BarriersNo signature needed. For review only.

35

UnityPoint: Corporate Compliance ProgramNo signature needed. For review only.

36

UnityPoint: Cultural Resource GuideNo signature needed. For review only.

37

Signature* This field is required.I attest that all of the information I have provided in this application is correct, accurate, and complete to the best of my knowledge.

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