Interpretive Services Request Form {IC-INT}

Claim Number: Interpretive Services Request Form The Industrial Commission provides interpretive services to Injured Workers or Employers who are hearing impaired or require a foreign language interpreter at hearings and medical examinations at no charge. The representative is responsible for requesting an interpreter for each hearing. To request interpretive services, please contact the Interpreter Coordinator in one of the following ways: Print form and mail to: Ohio Industrial Commission, Attn: Interpreter Services Coordinator, 30 W. Spring St. 1st floor, Columbus, Ohio 43215-2233 Call and request by telephone: (614) 466-6136 or 1-800-521-2691 Call and request by TDD: 1-800-686-1589 Print form and fax: (614) 728-7004 Email the information on this form: AskIC@ic.ohio.gov Should the need for this service change, please contact the Industrial Commission 24 hours prior to the hearing. Please complete the information below to aid in processing this request. Injured Worker's Information Name Address City, State, Zip Telephone Fax Name Address City, State, Zip Telephone Fax Employer's Representative Information Rep ID# Name Fax Telephone Fax (mm/dd/yyyy) (city) Employer Information Injured Worker's Representative's Information Rep ID# Name Telephone Date of hearing/medical examination where services are requested Location/office where service is to be performed Type of service needed (select one): Albanian American Sign Language Amharic Arabic Asanti Twi Ashanti Bosnian Bulgarian Burmese Chinese Mandarin Creole Croatian Egyptian Farsi French Fulani Greek Haitian Creole Hindi Italian Korean Laotian Macedonian Mai-mei Nepali Polish Portuguese Puerto Rican Punjabi Russian Serbian Shanghaniese Somali Soninke Spanish Tagalog Thai Tigrinia Turkish Ukranian Urdu Vietnamese Other: Applicant Name Signature Date American LegalNet, Inc. www.FormsWorkFlow.com An Equal Opportunity Employer and Service Provider Timely, impartial resolution to workers' compensation appeals IC-INT OIC-INT Rev. (02/17)