SOP 103.67-att-1: Interpreter Designation Form

SOP 103.67
Attachment 1

12/3/20

Timothy C. Ward

_Commissioner_

Brian P. Kemp
_Governor_

# GEORGIA DEPARTMENT OF CORRECTIONS _Office of Professional Standards_

_State Offices South at Tift College_

_P. O. Box 1529_
_Forsyth, Georgia 31029_

_Phone: (478) 992-5374_

_Fax: (478) 994-7752_

Limited English Proficiency (LEP) Plan
Language Interpreter Designation Form

I, __________________________, (Employee Name) hereby give my permission for the
Georgia Department of Corrections to use a language interpreter other than an appointed
representative from within the agency for the purposes of communicating medical, personnel, or
legal information on the date of service indicated. I understand that the interpreter will have
access to my medical and personnel information, only through the interpretation of oral and/or
written communications.

Language Required: __________________________________

_____________________________________________________________________
Employee Signature Date:

_____________________________________________________________________
Witness/Title Date:

To be completed by Interpreter:
______________________________________________________________________________

I, _________________________, (Interpreter Name), agree to accurately interpret written and/or
verbal communications from the above referenced employee for appropriate Georgia Department
of Corrections staff, agents, or representatives. I understand that my interpretation will remain
confidential with all parties involved and that my official translation may be used in accordance
with Georgia Department of Corrections internal investigations or third-party legal
representation.

_____________________________________________________________________
Interpreter Signature Date:

_Equal Opportunity Employer_

Retention Schedule: Upon completion, this form shall be retained permanently in the employee’s official
and local personnel files.