DD Form x561 Language Data Sheet

FOR NLSC USE ONLY
CONTROL NUMBER

NATIONAL LANGUAGE SERVICE CORPS (NLSC) PILOT
LANGUAGE DATA SHEET

OMB No.
OMB approval expires

PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION LISTED IN THE PARAGRAPH BELOW. RETURN COMPLETED FORM TO:
NATIONAL LANGUAGE SERVICE CORPS, P.O. BOX 12221, ARLINGTON, VA 22209-2221
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 131, Office of the Secretary of Defense; DoD Directive 5124.2, Under Secretary of Defense for
Personnel and Readiness; 50 U.S.C. 403-1b, War and National Defense; Public Law 109-364, Sec. 944, Administration of Pilot Project on Civilian Linguist Reserve Corps;
and Public Law 108-487, Sec. 613, Pilot Project on Civilian Linguist Reserve Corps. The OSD System of Records Notice name and number for this collection is National
Language Service Corps (NLSC) Pilot, DHRA 05.
PRINCIPAL PURPOSE(S): To allow U.S. citizens aged 18 years and older with language and special skills to self-identify language-related data for NLSC Pilot Charter
Membership. Those selected for activation and deployment will be officially tested to validate NLSC Self Assessment skills. The information collected will be used to
identify and contact NLSC Charter Members and prospective Charter Members in times of need. The collection will allow preliminary background checks prior to any final
appointment in the NLSC of only those individuals the NLSC expects to employ temporarily during the Pilot program. Background checks are not expected for the
remaining Charter Members.
ROUTINE USE(S): To Federal Government agencies requesting language support to facilitate U.S. efforts on the war on terrorism or in furtherance of national security
objectives. The DoD "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system.
DISCLOSURE: Voluntary. However, failure to provide information may result in non-enrollment in the NLSC Pilot, and refusal to grant access to Charter Member areas of
the NLSC Pilot Internet portal.

SECTION I - BASIC BACKGROUND INFORMATION
1. DID YOU GROW UP ABROAD? (X one)
3. WHAT IS YOUR NATIVE LANGUAGE?

YES

NO

2. ARE YOU A U.S. HIGH SCHOOL GRADUATE? (X one)

4. PRIMARY FOREIGN LANGUAGE?

YES

NO

5. LANGUAGE USED THE MOST IN YOUR HOME?

SECTION II - BACKGROUND FOR (Language)
6. WHERE DO YOU USE THIS LANGUAGE? (X all that apply)

HOME

WORK

RESEARCH

OTHER

7. NUMBER OF YEARS USING THIS LANGUAGE

8. NUMBER OF YEARS OF FORMAL TRAINING FOR THIS LANGUAGE

a. YEARS

a. YEARS

b. MONTHS

9. HOW OFTEN DO YOU USE THIS LANGUAGE? (X one)

b. MONTHS

ALWAYS

SOMETIMES

RARELY

SECTION III - LANGUAGE WORK HISTORY
10. HAVE YOU EVER WORKED AS:
(X all that apply)

(X one)
PAID
UNPAID

FROM:

TO:

a. INTERPRETER
b. TRANSLATOR
c. LANGUAGE TEACHER

Questions 11 - 13 focus on previous employment requiring professional use of your language skills other than those identified in Item 10. If needed,
please attach additional sheets.
13. DATES (YYYYMMDD)
11. JOB TITLE
12. JOB DESCRIPTION
FROM

TO

NEEDS DD 67
SECTION IV - LANGUAGE TESTING
14. HAVE YOU TAKEN ANY PROFICIENCY OR OTHER TEST FOR THIS LANGUAGE? (Test of English as a Foreign Language (TOEFL), Test of English
for International Communication (TOEIC), Defense Language Proficiency Test (DLPT), Oral Proficiency Interview (OPI), Advanced Program, (AP), International
Baccalaureate (IB), School Graduation, College Entrance, or other exams)
YES
NO (If No, please skip to Section V)
a. NAME OF TEST

b. TEST DATE (YYYYMMDD)

c. TEST SCORE

SECTION V - LANGUAGE LEARNING HISTORY
15. HOW DID YOU LEARN THIS LANGUAGE? (X all that apply)
a. AT HOME
AS A CHILD

b. COLLEGE STUDY IN THE U.S.
(1) NAME OF INSTITUTION:

(2) FIELD OF STUDY:

(3) DEGREE RECEIVED:

c. SCHOOL IN THE U.S. (K - 12)

f. AT COMMUNITY/CHURCH/SATURDAY SCHOOL IN THE U.S.

d. ATTENDED SCHOOL IN ANOTHER COUNTRY (Abroad)

g. DEFENSE LANGUAGE INSTITUTE FOREIGN LANGUAGE CENTER/OTHER USG
SCHOOL

e. AT HOME AS AN ADULT (e.g., with family/spouse)

h. WORKING ABROAD

DD FORM X561, 20080616 DRAFT

Reset

Adobe Professional 7.0