General Request Form - InterpreterRequests

Online State/Local Government Agency
Sign Language Interpreter/CART
Request Form THIS FORM IS FOR AUTHORIZED USE ONLY. (STATE/LOCAL GOVERNMENT EMPLOYEES)
Consumers seeking accommodations must contact the meeting/event organizer.

Communication Services needed:

Other communication services needed:

Requestor First Name: *

Requestor Last Name: *

Requestor Phone: *

Requestor Email: *

Additional emails or points of contact:

Agency Requesting Service: *

Is this assignment taking place at the above agency address?

Location Description:

Assignment Street Address 1:

Assignment Street Address 2:

Assignment Zipcode:

Assignment City:

Is this assignment scheduled to take place virtually?

Will this assignment be recorded/streamed?

If available, provide meeting link here:

Assignment Date(s): *

Please enter the date(s) an interpreter is needed. Click the Save button to ensure your changes are stored.

Comments about the scheduling of the assignment:

Size of Meeting:

Other Meeting size:

Provide a description of request/nature of assignment: *

Attach an agenda or available prep materials to your request:

OPTIONAL: Requested Interpreter/Provider(s):

VDDHH will take this preference into account, but assignment of the requested individual cannot be guaranteed.

Onsite Contact First Name: *

Onsite Contact Last Name: *

Onsite Contact Phone Number: *

Onsite Contact Second Phone Number:

Onsite Contact Email: *

Participants: *

Please enter the name of the person requiring accommodation and any other relevant parties including presenters and key hearing participants. Click the Save button to ensure your changes are stored.

Other communication needs:

By providing billing information, you acknowledge that you are authorized to ensure payment by the named entity.

Billing First Name: *

Billing Last Name: *

Billing Phone Number: *

Billing Email Address: *

Billing Street Address: *

Billing Street 2 Address:

Billing Zip: *

Billing City:

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