Full Name of Qualified Interpreter:* Interpreter Location (e.g., In-house, Via Phone, Via Video, Other):* Interpreter Agency (if applicable, or "In-house"): Interpreter ID Number (if applicable):

Interpreter Name:* Relationship to Patient:* Why was a family member used?* Emergency Patient declined qualified interpreter No qualified interpreter available Consent Form Signed:* Yes No

Reason no interpreter was used:* Patient fluent in English Clinician fluent in patient's language Interpreter not available