2021 Community Health Worker Institute Application Form

Community Health Worker Institute Application Form

Application Deadline - March 19, 2021
The Community Health Worker (CHW) institute is a two-day training (April 9th & 12th, 2021) which will occur prior to the National Latinx Conference on HIV/HCV/SUD. The institute will be all virtual through zoom.

Purpose & Work Plan: To end the HIV epidemic, stakeholders throughout the country will need to employ effective, evidence-informed approaches to improve health outcomes across the HIV care continuum. One such approach is the integration of community health workers (CHWs) into the HIV primary care team. CHWs, often called peer educators, outreach workers, navigators, or linkage to care coordinators, are critical members of the frontline public health workforce. The American Public Health Association (APHA) states that “[a CHW] is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”

The CHW Institute will be an interactive, skills-building institute for direct service and administrative staff who seek to implement a new or strengthen their existing CHW program. The institute seeks to achieve the following goals: 1) define the core competencies of CHWs working in HIV care 2) apply core competencies to case examples to build confidence in application of skills commonly employed by CHWs 3) identify resources that can support CHWs’ work with clients and support clinics in integrating CHWs as part of the HIV care team. To achieve these goals, training faculty will share evidence-informed models and tools that can be incorporated into Ending the HIV Epidemic plans or other work to improve outcomes across the HIV care continuum at a local level.

In order to participate in this institute, you need to fill out an application that will be reviewed by the institute trainers. Selected nominees will be notified on March 26, 2021.

Applicants strongly encouraged to apply are:

People living with HIV and allies who are interested in or already serving their communities as a CHW/peer/navigator/linkage to care coordinator.

Administrators who want to better understand how the role of a CHW/peer/navigator impact the HIV care continuum and become familiar with evidence informed models available for implementation in care teams.

CHW certification hours will be offered.
Agenda coming soon!
Read and Understand the aforementioned Institute description. *

Yes, I have
If you are planning on applying with 1-2 other work colleagues, please list their names below:
I. Personal Data:

Tell us about yourself
Full Name *

First Name Last Name
Birthdate: *

Month Day Year
Mobile No. : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
Agency that you are representing, if not applicable, enter your home address:

Agency Name

Street Address Line 1

City State / Province

Postal / Zip Code Country
If representing an agency, what is your title?
Gender:

Male Female Transman / Transgender Male Transwoman / Transgender Female Non-binary / Third Gender
What sex were you assigned at birth?

Male Female Decline to state
Race:

White Black or African American Asian American Indian or Alaskan Native, Hawaiian, or Other Pacific Islander
Ethnic Origin:

Hispanic Non-Hispanic
If Hispanic, please select your Ethnic Subgroup:

Mexican/Mexican American/Chicana/o Puerto Rican Cuban Salvadoran Dominican Guatemalan Colombian Honduran Ecuadorian Peruvian
What is your sexual orientation

Straight/Heterosexual Gay or Lesbian Bisexual Prefer not to say
What is your highest level of education?

High School 2 years of college BA/BS Master PhD MD
VII. Open Ended Questions
How many years of experience do you have in community health worker programming?
Describe your previous training or experience with community health worker programs?
What do you hope to learn at this training that you can take back to your organization?
The skills I want to learn from this training are: (select one)

I want to create a new community health worker program in my community / organization I want to strengthen an existing community health worker program in community / organization I want to strengthen my skills as a community health worker I want to strengthen my skills as the administrator and/or supervisor of a community health worker program
Tell us a bit more about the organization in which you want to create or strengthen community health worker services: (select all that apply)

Services are provided through a multi-disciplinary, team-based approach There are existing programs aimed to find and link clients who are currently lost to care, newly diagnosed or struggling with viral suppression The organization is a HRSA health center The organization is not a HRSA health center, but has on-site HIV medical care or has a partnership with the health center(s) in the community
VIII. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received.
E-Signature: *
Should be Empty:

Community Health Worker Institute Application Form

I. Personal Data:

VII. Open Ended Questions

VIII. Applicant's E-Signature