Medical Interpreter and Translator External Language and Interpretation Evaluation Form

This applicant is applying to be a volunteer medical interpreter at Free Access Health Clinic. As a free medical clinic serving uninsured and underinsured adults in Vermont, USA, and staffed by volunteers, we provide essential medical care to individuals of many backgrounds. We have an increasing number of patients whose primary language is not English, so we rely on volunteer medical interpreters to facilitate communication and thus insure high quality medical care.

Please complete the following form and, should you have questions or wish to discuss any part of your evaluation, please contact us at 802-488-5223 or When the form is completed, simply click on the “Submit” button at the bottom of the form. Thank you!

Applicant’s Name
Evaluator’s Name
Evaluator’s relationship to the applicant:
How long have you known the applicant?
Under what circumstances have you observed the applicant’s use of the identified language?
Are you a professional language educator?   

Are you a native speaker of the target language?

Are you familiar with the applicant’s current language abilities?

If your knowledge of the applicant’s abilities is not current, for what time period are you able to comment on their language abilities?
Are you aware of any translating or interpreting experience this applicant has had?

If yes, please briefly describe
Please describe any hesitations you may have about recommending this individual as a volunteer medical interpreter with our organization. You may attach additional pages as necessary.

Interpretation Performance Levels

Instructions: Please check the box next to the Level that best describes the applicant’s target language skills.

Thank you for your time and thoughtful feedback. By signing below, you indicate that, to the best of your knowledge, the information provided here is complete and accurate.

Evaluator’s Signature:
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