CHAPTER 4
FORMS
429—4.1(216A) Forms. All personal information provided on any form, made confidential by law, shall be held in strict confidence and maintained for three years unless otherwise defined in this rule.
	4.1(1) Client intake. Rescinded IAB 8/5/92, effective 9/9/92.
	4.1(2) Request form. This form is used by staff persons to document:
	a. 	Request date.
	b. 	Services provided.
	c. 	Parties involved.
	d. 	Date, time, and place of assignment.
	e. 	Setting number.
	f. 	Time spent providing the service, traveling, and waiting.
	g. 	Government setting number and other documentation related to the appropriate service.
Request form data is used for statistical purposes and destroyed after it is officially recorded in the annual report.
	4.1(3) Authorization for release of confidential information. This form is used to receive authorization from the client to release confidential information. This form is maintained in the client file for five years.
	4.1(4) Assistance/consultation release of information. This form provides for authorization from client to appropriate staff person for the purpose of providing assistance/consultation. This form is used by staff interpreters in the central and regional offices to relay information regarding issues needing assistance or consultation.
	4.1(5) Newsletter mailing list form. This form is used to record mailing information or changes of address of persons requesting this service. Information from this form is transferred onto computer and is a public record.
	4.1(6) Policies/procedures form. This form is used to define policies and procedures on program practices within the agency. Used primarily by the administrator with approval from the commission on the deaf, these forms will be maintained within the division and are open to the public.
	4.1(7) Census registry on the deaf. This form is used to collect information voluntarily submitted by the client and used for statistical purposes only.
	4.1(8) Contractual interpreting contract. This form is an agreement contract used by contractual interpreters and the division of deaf services to establish a mutual agreement regarding the special conditions set forth. Contracts are valid and maintained until the expiration date stated on the contract.
	4.1(9) Library information card. This standard information card establishes eligibility to borrow materials from the library.
	4.1(10) Check-out card. This form is used to record loaned materials from the library and is used to follow up on delinquent materials and for statistical purposes.
	4.1(11) Sign language interpreter release of information form. This form is required to be filled out by interpreters in private practice to be listed on the division’s public list of interpreters. Information requested relates to an individual’s certification, education in the interpreting field, and personal data. These forms are confidential although listings derived from these forms are made public to those consumers requesting the listings.
	4.1(12) TDD loaner bank application. Rescinded IAB 3/17/04, effective 4/21/04.
	4.1(13) Long distance telephone applications. Rescinded IAB 3/17/04, effective 4/21/04.
	4.1(14) Des Moines Metropolitan Transit Authority (MTA) forms. Rescinded IAB 8/5/92, effective 9/9/92.
	4.1(15) Interpreting service invoice. This form is used to invoice obligated agencies for interpreting services provided by division staff. Information included on this form is considered confidential and shall include:
	a. 	Client names.
	b. 	Date, time, and location of assignment.
	c. 	Setting description and rate.
	d. 	Hours of service delivery.
	e. 	Calculated fee-for-service.
	f. 	Name of interpreter.
	g. 	Account numbers, case numbers or other necessary information to verify services were provided.
This form is maintained in the division’s financial records for five years.
	4.1(16) Claim voucher for internal services. This form is used to transfer funds between state agencies. The division will initiate and complete the sellers account distribution section, voucher and date section and submit the multicopy form with the interpreting service invoices for that month to the state obligated agency for completion. The state obligated agency will make the transaction to transfer funds into the division’s revolving account. Revenue will distribute copies to the appropriate agencies. This form is kept with the division’s financial records for five years.
	4.1(17) Meeting/presentation request form. This form is used by staff to record requests for presentations and meetings handled by the division. Request form data is used for statistical purposes and destroyed after it is officially recorded in the annual report.
	4.1(18) Court proceedings waiver form. This form is used by staff who are not certified to provide services in court proceedings only when all reasonable efforts have been made to secure a certified interpreter and the case is either urgent or routine in nature. This form is to be used only when parties have waived the right to a certified interpreter and the administrator has been consulted.
This rule is intended to implement Iowa Code sections 216A.111 to 216A.117.
[Filed 6/12/87, Notice 4/8/87—published 7/1/87, effective 8/5/87]
[Filed emergency 8/19/88 after Notice 5/18/88—published 9/7/88, effective 8/19/88]
[Filed 9/23/88, Notice 7/27/88—published 10/19/88, effective 11/23/88]
[Filed 6/27/90, Notice 2/21/90—published 7/25/90, effective 8/29/90]
[Filed 7/16/92, Notice 5/27/92—published 8/5/92, effective 9/9/92]
[Filed 2/26/04, Notice 10/29/03—published 3/17/04, effective 4/21/04]