* NAME:

* DATE: 

PART ONE

* 1. Are you:

* 2. What is your primary method of communication? Do you use Sign Language, written notes, lipreading, FM system, loop system, or something else?

* 3. Do you use sign language? If so, what kind of sign language do you use? Do you use American Sign Language, Signed English, British Sign Language, or something else?

PART TWO
Please answer the following questions regarding your five (5) most recent visits to the doctor, hospital, clinic, ER, or other medical provider. Don’t worry if you can’t remember all of them. Any information you have is welcome.

* 1. Did you ask for a sign language interpreter before your visit? Did anyone ask you if you needed an interpreter?

If not, please skip to question two. If so,

* a. Did the doctor’s office/hospital/healthcare provider agree to provide and pay for an interpreter?

* b. Was there an interpreter there when you arrived or soon after?

* c. If so, did you have any difficulty communicating with your doctor and other staff through the interpreter?

* i. Did the interpreter use the wrong language?

* ii. Was the interpreter fluent?

* iii. Was the interpreter qualified?

* iv. Did the doctor give the interpreter time to sign and for you to respond?

* v. Did you have any other issues communicating? If so, please explain.

* 2. If you did not request an interpreter in advance, did you ask for an interpreter when you arrived?

If not, please skip to question 3. If so, 

* a. Did the doctor's office/hospital provide you with an interpreter?

* b. How long did it take for them to get an interpreter?

* c. Did you have any difficulty communicating with your doctor and other staff through the interpreter?

* i. Did the interpreter use the wrong language?

* ii. Was the interpreter fluent?

* iii. Was the interpreter qualified?

* iv. Did the doctor give the interpreter time to sign and for you to respond?

* v. Did you have any other issues communicating? If so, please explain.

3.      If you could not get an interpreter, or if you do not use sign language to communicate,

* a. What other ways did you communicate with your doctor and other staff? Did you use video relay interpretation, written notes, CART, FM system, loop system, friend or family interpreter, or something else?

* b. Did you have difficulty communicating with your doctor/other staff?

* i. Did the interpreter speak the wrong language?

* ii. Was the interpreter fluent?

* iii. Was the interpreter qualified?

* iv. Did the doctor give the interpreter time to sign and for you to respond?

* v. Did you have any other issues communicating? If so, please explain.

PART THREE
If you asked for an interpreter and did not get one, or if your interpreter was inadequate, please answer the following questions.

* 1. Did you complain to anyone at the office/hospital about not having an interpreter or otherwise being unable to communicate effectively?

* a. To whom did you complain? What was their response?

* 2. Did you complain to any outside organizations or agencies about not having an interpreter or otherwise being unable to communicate effectively?

* b. To whom did you complain? What was their response?

PART FOUR

* If you are comfortable, please provide the name and address of the doctor’s office(s), hospital(s), or medical provider(s) at which you had trouble communicating with staff because of a lack of interpreter or other alternative means of communication. The fact that you provided this information is confidential and will not be shared with anyone without your permission.

* Please provide any other information you think is relevant in the space below.

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