COMMUNITY HEALTH WORKER PROGRAM
First Name
*
Last Name
Middle (Optional)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (required for course access)
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Language
Other Language(s)
What racial, ethnic, or tribal background do you identify with?
*
Are you unemployed or employed?
Please Select
Unemployed
Employed
Are you seeking new skills to advance in current employment or as you look for another job?
Please Select
Yes, I am seeking new skills to advance in my current employment or as I look for another job?
No, I am not seeking new skills to advance in my current employment or as I look for another job?
Do you currently work as a Community Health Worker?
*
Yes
No
Unsure
How long have you been working as a CHW?
Months
Years
How often do you work as a CHW? (Check one
Daily
A few times/week
a few times/month
Not very often
N/A
If you have an organization that you work for or volunteer for as a CHW, please provide the name here
Please briefly tell us why you want to take the CHW Core Skills Training?
What are you passionate about in your community?
Do you plan to work as a CHW after the training?
Yes
No
Unsure
Are you willing to serve as a mentor for the next cohort of CHWs?
Yes
No
Unsure
Do you feel confident that you have English language reading / writing skills of level 6? (Note: If you believe you are not at this level, or are unsure, support and tutoring will be available in Spanish and Navajo)
Yes
No
Unsure
Do you have consistent and reliable access to a computer and Internet or the ability to access a local USU learning center?
Yes
No
Unsure
Would you prefer joining an online, self-paced classroom or an in person class at your local USU learning center
Online
In-Person
Unsure
How did you learn about this program?
Please Select
Website / Social Media
Event
Training Facilitator Outreach
Organization
At What Event did you hear about this program?
Name of the training outreach facilitator?
Please Select
Dani Rodriguez
Ginger Allen
Ryan Benally
What is the name of the organization you head about the program through?
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Optional Attachments:
- Resume evidencing experience with community health work
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- List of references / letter of references to speak to your work in the community.
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