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Annual Temporary Licensee Report Bureau of Professional Licensure Board of Sign Language Interpreters and Transliterators This information

is required as a condition of temporary licensure. The report must be completed, signed, dated and submitted each year to the Board by June 30th. (The first report is due June 30, 2008). Mail this completed form and any additional required information to: Iowa Board of Sign Language Interpreters and Transliterators Bureau of Professional Licensure Lucas State Office Building, 5th Floor 321 E. 12th Street Des Moines, IA 50319-0075
____________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

1. Name: __________________________________________

2. License number _____________________

3. Street Address:__________________________________________________________________ 4. City:___________________________ 5. State_____________ 6. Zip Code________________

7. Age Category: Place a check mark in your age category.
<20 21-30 31-40 41- 50 51-60 61-64 65>

8. How many times have you taken and not passed one of the approved examinations? None One Two Three Four Five Six Seven or more times 9. Education: Place a check mark in the box to indicate the highest education level attained (not necessarily in the area of interpreting)
Not Graduated From High School High School Diploma/GED AAS/Associates Degree College Bachelor’s Degree College Master’s Degree College Doctorate Degree Other

10. Have you graduated from a school for Interpreting/transliterating for the deaf or hard of hearing? Yes No 11. If you have graduated from a school for Interpreting/transliterating for the deaf or hard of hearing, identify that professional educational institution and year of graduation. a. Name of Institution _________________________________________________________ b. City and State _____________________________________________________________ c. Year of Graduation ________________ 12. How long have you practiced as an interpreter/transliterator for the deaf or hard of hearing?
Less than one year 1 year 2 years 3 years 4 years 5 years 6 to 9 years 10 or more years

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13. Current Employment Status
Interpreter/Transliterator Employment Full time Interpreter/Transliterator Part time Interpreter/Transliterator Not working as an interpreter/transliterator but seeking employment as an Interpreter/Transliterator Other Check Mark Other Employment Do you work Full time outside the field of Interpreting/Transliterating? Do you work Part time outside field of Interpretng/Transliterating? Full-time student Yes or No

14. Practice Setting: Please check mark only one box in each of the categories of Primary and Secondary Setting.
Primary Practice Setting Generalist Elementary School Middle School/High School College Medical Legal Other (please describe) Check only one Secondary Practice Setting Generalist Elementary School Middle School/High School College Medical Legal Other (please describe) Check only one if applicable

******Supervisor or Continuing Education Information****** As a temporary license holder you are required to either have a direct supervisor as you provide interpretative and/or transliterating services as required in 361.2(6)b(1) or annually complete 30 hours (3 CEUs) of continuing education in the area of professional studies that conforms to the requirements of 362.3(2)a(2). If you chose to complete 30 hours (3 CEUs) of continuing education submit with this form a copy of the certificates of completion you received at the end of each of the continuing education classes. The certificate of completion should have at a minimum the name of the course, the number of hours or CEUs of the course, the sponsoring agency, date of course completion and your name. 15. Do you have a written agreement with a Licensed by Examination Iowa Interpreter who is serving as your supervisor for purposes meeting your temporary license requirements? Yes No 16. If you have a written agreement with a direct supervisor provide the following information: a. Supervisor’s name: ________________________________________ b. Supervisor’s street address _______________________________________ c. Supervisor’s city ________________________________ d. Supervisor’s state _______________________________ e. Supervisor’s telephone number ______________________ 17. How many continuing education course hours (not CEUs) have you completed since July 1 of last year? Please check the appropriate number of hours even if you have chosen the option to have a direct supervisor. 1-5 hours 6-10 hours 11-15 hours 16-20 hours 21-25 hours 26-30 hours 31-35 hours 36-40 hours 41 or more hours 2

The Annual Temporary Licensee Report must be complete and signed to be processed. No report will be considered complete until all required information has been received in the board office. Questions regarding the application process may be directed to 515 281-4287 or khoover@idph.state.ia.us/licensure I certify that I have carefully read the questions on this report and have answered them completely and truthfully. I declare under penalty of perjury that my answers, and all other statements or information submitted by me in this report process, are true and correct. If it is determined at any time that I have provided misleading or false information on or in support of this report, I understand that I may be subject to disciplinary action and criminal prosecution if I am already licensed. I understand that this application is a public record in accordance with Iowa Code, Chapter 22 and that report information is public information, subject to the exceptions contained in Iowa law. Finally in submitting this report, I consent to any reasonable inquiry that may be necessary to verify the information I have provided on or in conjunction with this report. *This information is collected pursuant to Iowa Code Chapters 154E, 252J, 261 and 272C. Failure to provide mandatory information will result in license denial and/or discipline. Disclosure of your social security number is required by IAC 645-14.1 & 15.1.

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Licensee must sign here in ink

Date

File=Wilson/interpreters/Template for Temporary License Annual Report

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