Inclusive and Equitable

This is a brief summary of the key findings of the EtoE Interpreter Testing Study.

This Report provides results of the comparison of CCHI candidates’ performance on the monolingual EtoE exam to the dual-language CHI™ certification exam. These findings offer data-based evidence to the possibility of measuring cognitive interpreting skills responsible for a successful conversion of meaning from one language into another in a monolingual format.

A total of 249 interpreters of Arabic, Mandarin and Spanish took the EtoE and CHI™ examinations between January 24 and November 3, 2020, with 247 of them also completing the EtoE Study Participant Questionnaire. All 249 participants have completed both exams, and 177 of those had the full sets of the exam items completed.

The report consists of Part I describing the EtoE exam development and study participants, Part II containing the psychometric analyses prepared by Prometric LLC for CCHI, Part III providing some additional observations relevant for interpreter educators and the profession at large, and Appendices. Appendix A is the National Task Force Recommendations on Designing the English-To-English Interpreting Performance Test. Appendix B is a sample Performance Item Template for the EtoE Examination that has been used by SMEs to write items for the exam. The item review forms are provided in Appendices C and D. Appendix E contains the EtoE Study Participation Questionnaire. Appendix F is the EtoE Examination Guide that participants were encouraged to review before taking the exams in order to familiarize themselves with the test tasks; it also contains sample exam items. Appendix G provides an example of the scoring scales used by raters to score the EtoE exam. Appendix H clarifies some statistical terms used in Prometric’s report of Part II, while Appendix I contains loading factors of the three confirmatory factor analysis models.

CCHI will take into account the EtoE Study findings to develop the future monolingual ETOE™ credentialing examination for healthcare interpreters. This future exam will allow to assess interpreting ability of candidates working in languages of low incidence, thus, ensuring equity and inclusiveness of CCHI’s certification program. At the same time, CCHI will continue administering and developing bilingual interpreter performance exams for languages of high incidence (such as currently administered Arabic, Mandarin and Spanish CHI™ exams).

The Commissioners decided to publish this Preliminary Report based on the exams administered from January 24 until March 17, 2020. CCHI  continues administering the EtoE and CHI™ exams to study participants until November 3, 2020. The final report is expected to be published in early 2021.

This Preliminary Report is intended to provide some preliminary results of the comparison of CCHI candidates’ performance on the monolingual EtoE exam to the dual-language CHI™ certification exam. These findings provide the first data-based evidence to the possibility of measuring cognitive interpreting skills responsible for a successful conversion of meaning from one language into another in a monolingual format.

The Guide describes the structure and design of the ETOE™ exam, the exam appointment logistics, and contains sample questions (with answers).

Click on the button below to view/download the Guide in the pdf format.

CCHI expresses its gratitude to the volunteer subject matter experts (SMEs) who helped develop the ETOE™ exam content and rating scales. The dedication of these individuals – who volunteered countless hours to CCHI – was critical in creating the ETOE™ examination:

Sura Al Khalidi, CHI™- Arabic (CA)
Mutaz Al Mudaris, CHI™- Arabic (PA)
Yasmeen Albarghouthi, CHI™- Arabic (OR)
Chi-Wei Chang, R.N., CHI™- Mandarin (MI)
Carla Chavez Moreno, Ph.D. (MD)
Suzanne Couture, CHI™-Spanish (WI)
Ping Cross, CHI™- Mandarin (TN)
Jose Cruz, CHI™- Spanish, CMI (TN)
Jaime Diaz, CHI™- Spanish (IL)
Maria Donley, CHI™- Spanish (IL)
Lois Feuerle, J.D., Ph.D. (OR)
Jeffrey Gabbitas, Ph.D. (AZ)
Emil Gilmanov, CMI, Russian (MN)
Elisa Gustafson, CHI™- Spanish (MN)
Erika Hernandez, CHI™- Spanish (NC)
William (Will) Hester, CHI™- Spanish, CMI (IL)
Jacqueline Hinds, CHI™- Spanish (OR)
Dan Kristie, B.A. (PA)
Katherine Langan, Ph.D., CHI™- Spanish (IA)
Sandy Maloney, CHI™- Spanish (MN)
Myrlande Merisme, Haitian Creole interpreter (NY)
Laura Neri, CHI™- Spanish (CA)
Laura Onofre, CHI™- Spanish (CA)
Linda Pollack-Johnson, CoreCHI™, Italian interpreter (PA)
Myriam Prias, CHI™- Spanish (FL)
Ronda Rankin, CoreCHI™, NIC, ASL interpreter (NE)
Rosemary Rodriguez, CHI™- Spanish (VA)
Karin Ruschke, M.A., German interpreter (IL)
Aida Schneider, CHI™- Arabic (OH)
Tatyana Sorensen, CoreCHI™, Russian interpreter (UT)
Sarah Stockler-Rex, CHI™- Spanish (OH)
Indira Sultanic, Ph.D., CHI™- Spanish (VA)
Qing Xiu (Linda) Sun, CHI™- Mandarin (NV)
Manyee Tang, CHI™- Mandarin, CMI (MA)
Icarus Tsang, Psy.D. (2021) (CA)
Rio Zamarron, MHPE (MO)

Enrica Ardemagni, PhD, CHI™-Spanish, is Professor Emerita of Spanish for World Languages and Cultures at IUPUI. B.A. University of Arkansas, M.A. University of Arkansas, Ph.D. University of Wisconsin, Certified Trainer in Cultural Competency Graduate Certificate in Medical Interpreting, Indiana Supreme Court Certified Court Interpreter. Service: President, School of Liberal Arts Faculty Assembly; President, National Council on Interpreting in Health Care; Past Administrative Chair, American Translators Association (ATA) Literary Division, Past President/Founding Member Midwest Association of Translators and Interpreters; Administrator ATA Educators Division.

Rosanna Balistreri is a trilingual speaker of Spanish, Italian & English.  She holds a B.A. in Linguistics with a Certificate of Teaching English as a Second Language (TESL), and an M.A. in Spanish Linguistics. In 2010 & 2011, Miss Balistreri served as President of the California Healthcare Interpreting Association.  She has also served as Subject Matter Expert (SME) for the Certification Commission for Healthcare Interpreters (CCHI) and is presently Member of the National Council of Interpreters in Health Care (NCIHC) Standards and Training Committee and a member of the Language of Lesser Diffusion (LLD) Workgroup. Currently, Miss Balistreri teaches Translation and Interpreting at Cal State University Fullerton and owns REACH-reaching diversity, a consulting agency for cultural & linguistic services geared exclusively toward healthcare.

Joy Connell has 30 years of service with community-based organizations, with a focus on refugees and immigrants, and a passion for linguistic access for Limited English proficient groups seeking health care. She has been involved with the Massachusetts Department of Mental Health’s (DMH) Interpreter Services program since its inception in 1988. In addition to program coordination, she developed and presented numerous trainings to both interpreters and providers working with interpreters. Ms. Connell has been involved in language access work on a national and state levels, having served as Co-Chair of the National Council on Interpreting in Health Care and President of MMIA.

Esther Diaz, M.A., CHI™ – Spanish, is an interpreter trainer and translator, a founding member of the Texas Association of Healthcare Interpreters and Translators, and former Medical Division Administrator for the American Translators Association(ATA). She has served in a variety of capacities with the Austin Area Translators and Interpreters Association, and the National Council on Interpreting in Health Care. She learned Spanish while living and studying in Mexico for ten years and is certified by the ATA for translation Spanish ><English. Esther has more than 30 years of experience as a medical translator and trainer. A co-founder of the Austin Area Translators and Interpreters Association, Esther also created the seven-course Translation and Interpretation Certificate Program at Austin Community College. She has taught interpreter workshops for refugee resettlement agencies throughout Texas and is an adjunct faculty member of Austin Community College. Esther received her Bachelor of Arts in Spanish and Master of Education in Adult Education and Human Resource Development Leadership from the University of Texas at Austin.

Nora Goodfriend-Koven, MPH, has been dedicated to issues of equity and health for over 3 decades.  Presently she is a free-lance Spanish interpreter and a trainer of interpreters. A former fulltime and currently adjunct professor at City College of San Francisco (CCSF) in the Health Education Department, Ms. Goodfriend-Koven was the lead instructor coordinator of the HealthCare Interpreter Certificate Program. She also taught “Trauma Response and Recovery” and continues to provide workshops on the interface of interpreting and mental health issues.  Prior to her work at CCSF Nora worked for the San Francisco public health department where she provided community-based prevention programs to the Latino and Spanish speaking community. She did similar trainings in Belarus and Ukraine for survivors of the Chernobyle nuclear reactor explosion.  Nora is a lead author of Healing Voices, a 1-week training for experienced interpreters who interpret in extreme circumstances of torture and trauma survivorship.  Nora has also consulted internationally on the topics of HIV/AIDS prevention (Guatemala, Bolivia and Peru) and disaster mental health (Belarus, Ukraine).  She is on the board of directors of the California Healthcare Interpreting Association and Walden Center and School, an arts-based primary non-profit educational institution. She is a certified Administrative Hearing Interpreter in the state of California for Spanish/English interpretation.  Ms. Goodfriend-Koven received her BA in Latin American Studies and Anthropology from UCSC, and her MPH in Health Education from SJSU.  She resides in the East Bay and in West Marin.

Carola E Green, BS in Communication, federally certified English/Spanish court interpreter and former California state court interpreter is originally from Guatemala. She served as key staff for the Federal Court Interpreter Certification Examination (FCICE) and the Consortium for Language Access in the Courts (CLAC) programs at the National Center for State Courts. Ms Green is a founding member of the California Healthcare Interpreting Association (CHIA) and the National Council on Interpreting in Health Care (NCHIC) and co-authored seminal publications like CHIA’s California Standards for Healthcare Interpreters and NCIHC’s A National Code of Ethics for Interpreters in Health Care.

Manuel Higginbotham, CHI™ – Spanish, is a linguist with a passion for advocating on behalf of the Limited English Proficient community. He has leadership experience in hospital and VRI/OPI arenas.  More than 40 hospitals across the US have relied on his expertise in developing language access plans and training interpreters. Manuel oversees the Language Access Services Department for hospitals within the State of Texas medical system. He has also trained more than 750 interpreters as the founder and CEO of Tex-Med Training Services, which provides a variety of CEU opportunities and 40-, 65-, and 80-hour trainings. He currently serves as the president of TAHIT, the Texas Association of Healthcare Interpreters and Translators.

Jane Crandall Kontrimas, CoreCHI™, M.S., is a Russian Interpreter, Interpreter Training Coordinator, and Interpreter Ethics Liaison at Beth Israel Deaconess Medical Center. She began working at Beth Israel in 1979. In 1985 she and Raquel Cashman, hosted the first meeting of what became the Massachusetts Medical Interpreter Association. She co-authored the first MMIA Code of Ethics in 1987, chaired the MMIA Standards of Practice Committee to produce the  “Standards of Practice for Medical Interpreters” in 1995. She chaired the Certification Committee of the MMIA until December 2007. In 2016 she was a CCHI subject matter expert for Job Task Analysis review.   She trains interpreters, and clinicians.

Katherine Langan, Ph.D. CHI™, CMI-Spanish, is a sociolinguist who has worked as a full time or occasional translator/interpreter since 1979.  She earned her Ph.D. and M.S. at Georgetown University in Washington, D.C. She received her training in translation through SIL and has worked with various combinations of Indo-European and Mayan languages including English, Spanish, Poqomam, K’iche’, Kaqchikel, Koiné Greek and French, working with religious, technical, cultural, medical, legal, and commercial documents. She has been involved in the training of interpreters and translators both in the US and Guatemala since 1979.  She has interpreted in legal, educational and medical contexts in both the U.S. and Guatemala and has also done conference interpreting.  As an active member of the National Council on Interpreting in Health Care she is the Chair of the Standards and Training Committee coordinating the work of the Home for Trainers and co-chairing the Languages of Limited Diffusion Work Group and the National Standards of Practice for Healthcare Interpreters Work Group.  She has researched and developed specialized training for interpreters working in speech language therapy contexts.  She is launching a company to provide educational opportunities ranging from introductory courses to specialized topics for interpreters and consumers. She is currently learning German for the fun of it.

Elena Langdon, M.A., CT, CoreCHI™: A Brazilian at heart, Elena Langdon has worked as an interpreter and translator since 2000. She is certified by the American Translators Association as a translator (Portuguese into English) and by the Certification Commission for Healthcare Interpreters as a core-certified healthcare interpreter. She holds a Master’s in Translation Studies and has been teaching interpreting and translation since 2005. Elena was chairperson of the National Board of Certification for Medical Interpreters and currently helps produce webinars for interpreter trainers for the National Council on Interpreting in Health Care. She recently left a full-time job supervising 50+ hospital interpreters in Massachusetts to focus on teaching and language access consulting.

Gerardo Lázaro, Bachelor in Science (Biology) and Education, completed Master’s of Education (Peru), and currently a Ph.D. Student in Public Health (USA). He started working in Human Assisted Reproduction in Peru (3 years) and in the US (4 more years). A career change led him to work as a Master Medical Interpreter in the major hospitals of the Philadelphia Metropolitan Region where he co-developed training programs for Coordinated Healthcare, Cultural Competency, and healthcare related topics. He is a trainer with the National Institute for Coordinated Health Care (NICHC). As a Ph.D. student in Public Health, he has found the niche in improving health care primarily for low-income, immigrants, and limited-English proficient people.

Jonathan Levy, M.A., has over 18 years of experience in the language services industry. A past assistant director of the University of Arizona’s National Center for Interpretation, he currently serves as a commissioner on the Certification Commission for Healthcare Interpreters. He has developed interpreter training and testing programs for a wide range of clients, including the Defense Language Institute Foreign Language Center, the U.S. Army, and the Georgia and Utah state courts. As the senior director of Language Solutions at TransPerfect, he oversees interpreting service quality and government language initiatives. He has an MA in cultural studies and a BA in Asian history.

David McCoy-Galicia, CHI™, CMI is the director and creator of Medical Interpreting Training School (MITS). David has been an educator for more than twenty years. He has extensive experience in developing tests and curricula for ESL and interpreting courses. Throughout his teaching career, he has interacted with thousands of students of different ages, backgrounds, and languages. David holds a CHI™ and CMI certification. He has over ten years of experience working as a healthcare interpreter in many medical specialties, ranging from neonatal to geriatrics. For many years, David has been an avid advocate for improving the quality of language services to LEP patients across the country.

Tim Moriarty, MPA, CMI-Spanish, CHI™-Spanish, has been manager of Interpreter & Translation Services for Baystate Medical Center for 16 years, and is responsible for interpreter services throughout the Baystate Health System in Western Massachusetts.  His department consists of 50 staff interpreters who speak English and 11 different languages.  Tim has a BA in Hispanic Studies and a Master’s in Public Administration from Columbia University.

Johanna Parker, MA, CHI™-Spanish, holds an M.A. in Translation and Interpretation (Spanish <>English) from the Middlebury Institute of International Studies at Monterey (MIIS) and is a federally and California certified court interpreter and CCHI Certified Healthcare Interpreter™.  She is Lead Interpreter for Education and Training at Stanford Health Care, a freelance conference interpreter and translator, and a seminar interpreter for the U.S. Department of State. Johanna trains healthcare and court interpreters around the country and is an adjunct professor at MIIS, where she teaches medical interpreting.  She was awarded the California Healthcare Interpreting Association’s Trainer of the Year award in 2015.

Cynthia E. Roat, MPH, is an international consultant on language access in health care and patient navigation. Over the past 25 years, Ms. Roat has made significant contributions to the field as an interpreter, teacher, consultant, organizer, researcher, mentor and author. Her most recent book, Healthcare Interpreting in Small Bites, is being adopted as an ancillary text in many interpreter training programs. From 2012-2015, she managed Seattle Children’s Hospital’s innovative Bilingual Patient Navigation program. She is a founding member and former board chair of the National Council on Interpreting in Health Care, a founding member of the Washington State Language Access Coalition, and current chair of the Northwest Translators and Interpreters Society’s Community Interpreter Division. She is known nationally as an engaging speaker, a knowledgeable resource, and an energetic advocate for language access in general.

Karin Ruschke, M.A., CoreCHI™, owns International Language Services, Inc., a full-service interpreting agency providing telephone and on-site interpreting, written translation services and training to clients nationwide. She has developed a comprehensive 65-hour training program improving the professionalism of interpreting by going beyond basic classroom instruction to include a rigorous mentorship program. Karin is one of the founding CCHI Commissioners and served in 2009-2015. She ended her service as a board member of the National Council on Interpreting in Health Care in May 2011 after co-chairing the Standards, Training and Certification Committee (STC) from 1999 – 2011, during which time the committee published the National Code of Ethics and Standards of Practice for Interpreters in Health Care, as well as National Standards for Healthcare Interpreter Training Programs. A technical advisor on The Joint Commission research project, Hospitals, Language and Culture: A Snapshot of the Nation, Karin was one of only 26 members on the expert advisory panel for the Commission’s project, Developing Hospital Standards for Culturally Competent Patient-Centered Care: A Roadmap for Hospitals.

E. Zoe Schutzman, MA, NYS-Certified Court Interpreter & CHI™-Spanish, is presently Educator & Staff Development Specialist at The University of New Mexico Health Science Center’s UNM Hospitals in Albuquerque, New Mexico. As a linguist, she has taught at institutions of higher education and trained individuals to become qualified medical interpreters. She has developed and enhanced curricula, assessment and quality assurance protocols, and provided linguistic and culturally appropriate expertise to research endeavors. Her contributions have extended to meaningful access to healthcare services for immigrant communities with limited English proficiency; sociolinguistic, language acquisition and language documentation projects; analysis of internal and national regulatory policies; and development, translation and trans-creation of research, outreach, and educational materials.

Judy Shepard-Kegl, CoreCHI™, is certified by The Registry of Interpreters for the Deaf, the National Association of the Deaf, and CCHI. She coordinates an interpreter training program nationally accredited by the Collegiate Commission on Interpreter Education (CCIE; http://ccie-accreditation.org/accredited-programs/). She served two terms as Commissioner and Executive Board member for CCIE.  One of her duties was revising the national standards for Interpreter Training Programs.  She earned her MA in linguistics at Brown University (1975; Slovene-English Bilingualism) and her Ph.D. in linguistics from M.I.T. (1985; American Sign Language Word Formation, Syntax and Discourse. She has over 100 published articles and books and has served as a reviewer for journals and granting agencies.  As a tenured professor at the University of Southern Maine, her duties include teaching three courses on Healthcare Interpreting. She has been working as a healthcare interpreter since 1977. She is fluent in English, ASL, Spanish and Nicaraguan Sign Language.

Gabriela Siebach, M.A., CHI™-Spanish, is the Sr. Advisor for MasterWord’s Training and Assessments Team. Her experience in translation, interpreting, and language program management makes her uniquely suited to provide support in ensuring that MasterWord’s language experts are qualified to meet each client’s needs, as well as to provide continuing education and training for interpreters and translators. She is a Certified Healthcare Interpreter (CHI), has accumulated more than 10 years of professional experience in linguistics and spearheaded the development of multiple training, mentorship, and assessment programs. She has a Masters in Translation and Interpretation from the Middlebury Institute of International Studies at Monterey.

Monica Thomasini is a CoreCHI™ certified interpreter with six years of professional interpreting experience and Quality Assurance Trainer for Language World Services. Monica is a skilled trainer and manages the production and delivery of all of Language World Services’ customized interpreter education programs. Monica is fully informed of the legalities and protocols required of medical interpreters and is charged with managing the quality and performance of our entire workforce.

Melissa Wallace, PhD, CHI™-Spanish, received her Ph.D. in translation and interpreting studies from the Universidad de Alicante, Spain. A certified court interpreter and certified healthcare interpreter, Wallace is currently serving a 5-year term on the Licensed Court Interpreter Advisory Board of the Judicial Branch Certification Commission for the Supreme Court of Texas. She has been an active member of the Home for Trainers Webinars Work Group at the National Council on Interpreting in Health Care since 2012, and is a board member of the Society for the Study of Translation and Interpretation (SSTI), the non-profit educational and research foundation of the National Association of Judicial Interpreters and Translators. Her research focuses on indicators of aptitude on court interpreter certification exams, accreditation exam models, and interpreter and translator training. Wallace carried out research on court interpreting certification models in Finland in 2016 as the Fulbright-University of Tampere Scholar. She is an Assistant Professor of TI Studies at the University of Texas at San Antonio where she directs the graduate certificate program in translation and interpreting studies.

In the Fall of 2017, CCHI held several focus group calls and interviews with 40 national experts on healthcare interpreting and/or interpreter testing about the interest for and feasibility of creating a monolingual exam that can assess cognitive interpreting abilities.

In healthcare and other interpreting settings, the interpreter’s competencies include skills that have either no direct correlation to language proficiency or are not exclusive to language proficiency. Some of these competencies include knowledge, cognitive skills, and personality traits.

Professional interpreters are acutely aware that skills such as memory recall, active listening, message analysis, and speech quality are just a few of the subskills that are essential to rendering a successful interpretation. While these skills are among the critical competencies for interpreters, they do not necessarily require knowledge of a second language. This raises several questions regarding the feasibility of testing performance-based interpreter competencies. Is it possible to test an interpreter’s performance-based competencies using a monolingual modality? If so, how could this be done?

The complete summary of these discussions is published in the paper Assessing Healthcare Interpreting Performance Skills in and English-to-English Format. Click the button below to view and download the full whitepaper.

Poster at CHIA’s 2019 conference

Presentation at 2019 Utah Language Access Conference

Presentation at 2019 conference of New England Translators Association

Presentation at NATI’s 20th Annual Conference (August 2-3, 2019, Omaha, NE)

Interpreter Performance/Skills Testing: Assessment of an individual’s ability to convert a message from one language into another accurately and completely in a spoken or signed format. Interpreting tests include assessment of an individual’s ability to perform competently in the three interpreting modes – consecutive, simultaneous, and sight translation. Usually such testing is targeting a specific domain of interpreting, e.g. healthcare/medical, court/legal, conference, business, social services, education. CCHI’s certification exams are examples of such testing.

Language Proficiency Testing: Assessment of an individual’s ability to communicate or perform in a specific language. Proficient speakers demonstrate both accuracy and fluency, and use a variety of discourse strategies. There are several reputable tests of language proficiency utilizing different language proficiency scales.

Language proficiency scales: Below are examples of the most commonly used scales.

ILR scale: Interagency Language Roundtable descriptions of proficiency levels 0, 1, 2, 3, 4, and 5 characterize spoken-language use (http://www.govtilr.org/Skills/ILRscale1.htm).

ACTFL scale: Developed from the Federal Government’s ILR scale by the American Council on the Teaching of Foreign Languages, the ACTFL proficiency scale has four main levels (Novice, Intermediate, Advanced, Superior). The first three levels are each subdivided into three sublevels (Low, Mid, and High) (https://www.languagetesting.com/actfl-proficiency-scale).

CEFR scale: The Common European Framework of Reference for Languages: Learning, Teaching, Assessment is a guideline used to describe achievements of learners of foreign languages across Europe and, increasingly, in other countries. The CEFR distinguishes between four kinds of language activities: reception (listening and reading), production (spoken and written), interaction (spoken and written), and mediation (translating and interpreting). Four broad domains are distinguished: educational, occupational, public, and personal. A language user can develop various degrees of competence in each of these domains and to help describe them the CEFR has provided a set of six Common Reference Levels (A1, A2, B1, B2, C1, C2). (http://ebcl.eu.com/uploads/2011/11/CEFR-all-scales-and-all-skills.pdf)

IELTS scale: The International English Language Testing System is an international standardized test of English language proficiency for non-native English language speakers. It is jointly managed by the British Council, IDP: IELTS Australia and Cambridge English Language Assessment. No minimum score is required to pass the test. An IELTS result or Test Report Form is issued to all test takers with a score from “band 1” (“non-user”) to “band 9” (“expert user”) and each institution sets a different threshold. (https://www.ielts.org/en-us/about-the-test/how-ielts-is-scored)

TOEFL scale: Test of English as a Foreign Language is a standardized test to measure the English language ability of non-native speakers wishing to enroll in English-speaking universities. TOEFL is scored on a scale of 0 to 120 points by adding scores from each of the four sections (Reading, Listening, Speaking, and Writing) which each receives a scaled score from 0 to 30. The test is accepted by many English-speaking academic and professional institutions; each institution establishes the minimally accepted score which varies from 61 to 111. (https://www.ets.org/toefl/institutions/scores/interpret/)

EtoE interpreter performance exam: This is a proposed working term for a monolingual, English-to-English, oral performance examination of healthcare interpreters that assesses the interpreter’s core cognitive skills responsible for a successful conversion of meaning from one language into another and whose scoring is based on evaluating the exam’s English input to the candidate’s English output.

Languages of limited diffusion (LLD): Languages of relatively small population of patients with LEP residing across the U.S. and which have no educational opportunities for studying these languages available in the U.S. (e.g., Burmese, Hmong, Kirundi, Mayan languages, Nepali, Somali). For example, there are over 30,000 Somalis residing in Minneapolis, MN, and Columbus, OH, each, yet very few outside these two cities, and there are no college-level programs teaching the Somali language in the U.S.

Languages of lesser demand: Languages of relatively small population of patients with LEP residing in a specific geographic area in the U.S., but which have reasonably accessible educational opportunities for studying these languages available in the U.S. (e.g., French, German, Japanese). For example, the demand for interpreters of Japanese may be non-existent in Akron, Ohio, yet significant in Los Angeles, CA, and at the same time there are quite a few college-level programs teaching Japanese in the U.S.

Less Common Languages: The term that is used to refer to both languages of lesser diffusion (LLD) and languages of lesser demand. Recognizing that this is not an ideal term, it is used for the sake of efficiency.