Bilingual Staff Language Proficiency Verification Form

Documents the method, rater, and result used to verify spoken and written proficiency for staff providing services in a second language. Used by HR to support bilingual differential pay and language-access compliance.

Staff Member Information

• Employee Full Name
• Employee ID / Personnel Number
  Enter your organization-assigned employee ID. Do not enter Social Security Number.
• Department / Work Unit
• Job Title
• Direct Supervisor Name
• Date of Assessment
  Date on which the proficiency assessment was conducted.
• Purpose of This Assessment
• If Other, please describe

Language Being Assessed

• Second Language Being Assessed
  Select the language in which the employee will provide services.
• If Other, specify language
• Dialect or Regional Variant (if applicable)
  Specify if the employee's proficiency is specific to a dialect relevant to the population served.
• Modalities in Which Employee Will Use This Language
  Select all that apply. Proficiency must be verified for each selected modality.

Assessment Method and Rater

• Primary Assessment Method Used
  Select the primary method used to evaluate proficiency. Self-attestation alone is not sufficient for language-access compliance.
• If Other, describe the method
• Assessment Tool / Test Name and Version (if applicable)
  Include version or edition if known to support audit trail.
• Rater / Assessor Full Name
• Rater Title or Role
• Rater Credential or Qualification
  Select the credential that qualifies this rater to assess proficiency.
• Additional Rater Credential Notes

Proficiency Results — Spoken Language

• Was spoken / oral proficiency assessed?
• Spoken Proficiency Level Achieved
  Select the level that best corresponds to the assessment result. ACTFL scale: Novice → Intermediate → Advanced → Superior → Distinguished. ILR scale: 0–5.
• Raw Score or Numeric Result (if applicable)
  Enter the score as reported by the testing tool, if numeric.
• Does spoken proficiency meet the minimum threshold for this role?
  The minimum threshold should be defined in your organization's language-access policy. Typically Advanced Low (ACTFL) / ILR 2+ for direct service roles.
• Spoken Assessment Notes

Proficiency Results — Written Language

• Was written proficiency assessed?
• Written Proficiency Level Achieved
  Select the level that best corresponds to the written assessment result.
• Raw Score or Numeric Result (if applicable)
• Does written proficiency meet the minimum threshold for this role?
• Written Assessment Notes

Supporting Documentation

• Upload Supporting Documents
  Accepted formats: PDF, JPG, PNG, DOCX. Maximum 10 MB per file. Examples: ACTFL score report, CMI certificate, transcript, internal assessment scoring rubric.
• Brief Description of Uploaded Document(s)
• Credential or Certificate Expiration Date (if applicable)
  If the attached credential has an expiration date, enter it here so HR can schedule re-verification.

HR Determination and Authorization

• Overall Proficiency Determination
  HR's official determination based on all assessed modalities.
• Bilingual Differential Pay Authorized?
  Authorization is contingent on meeting the minimum proficiency threshold defined in the organization's compensation policy.
• Bilingual Differential Pay Effective Date
  Enter the date from which the bilingual differential pay will be applied, if authorized.
• Next Re-Verification Due Date
  Set a re-verification date consistent with your organization's language-access policy (typically every 1–2 years, or upon role change).
• HR Reviewer / Language Access Coordinator Name
• HR Reviewer Title
• Date of HR Review
• HR Reviewer Notes

Employee Acknowledgment and Consent

• Assessment Results Disclosure
  Your proficiency assessment results will be stored in your personnel file and used solely for the following purposes: (1) determining eligibility for bilingual differential pay; (2) assigning language-access duties; and (3) demonstrating compliance with Title VI of the Civil Rights Act, Executive Order 13166, and applicable state language-access laws. Results will not be shared with unauthorized parties. You have the right to request a copy of this record from HR.
• I have read and understood the above disclosure. I consent to the collection and use of my language proficiency assessment results for the purposes described.
• I confirm that the assessment results recorded in this form accurately reflect the assessment conducted on the date indicated.
• Employee Signature
  Sign to acknowledge the accuracy of this record and your consent to its use.
• Date Signed