Templates › Forms › SEO page

Run: Bilingual Staff Language Proficiency Verification Form

Verify a staff member’s spoken and written proficiency in a second language, document who rated it, and record the HR decision for bilingual pay or language-...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Staff Member Information

Employee Full Name (required)

Employee ID / Personnel Number (required)

Enter your organization-assigned employee ID. Do not enter Social Security Number.

Department / Work Unit (required)

Job Title (required)

Direct Supervisor Name (required)

Date of Assessment (required)

Date on which the proficiency assessment was conducted.

Purpose of This Assessment (required)

If Other, please describe

Language Being Assessed

Second Language Being Assessed (required)

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 (required)

Select all that apply. Proficiency must be verified for each selected modality.

Assessment Method and Rater

Primary Assessment Method Used (required)

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 (required)

Rater Title or Role (required)

Rater Credential or Qualification (required)

Select the credential that qualifies this rater to assess proficiency.

Additional Rater Credential Notes

Proficiency Results — Spoken Language

Was spoken / oral proficiency assessed? (required)

Spoken Proficiency Level Achieved (required)

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? (required)

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? (required)

Written Proficiency Level Achieved (required)

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? (required)

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 (required)

HR's official determination based on all assessed modalities.

Bilingual Differential Pay Authorized? (required)

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 (required)

HR Reviewer Title (required)

Date of HR Review (required)

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. (required)

Yes No N/A

I confirm that the assessment results recorded in this form accurately reflect the assessment conducted on the date indicated. (required)

Yes No N/A

Employee Signature (required)

Sign to acknowledge the accuracy of this record and your consent to its use.

Date Signed (required)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free