Community Health Worker Training - Scholarship Application (MK)

Community Health Worker Training Scholarship Application
Full tuition scholarships are available to learners for interactive cohorts in 2024. Please complete this form to be considered for a scholarship.

Please add CHW@CEimpact.com to your email contact list to ensure you receive future communications about your application. Please also check your junk email folder periodically to be sure you do not miss important information.

Cohort Timeline
- January 23, 2024 - May 7, 2024
- Class meets every Tuesday evening from 6PM-8PM CST for a total of 16 weeks.
- Reading and homework assignments are required as part of the course.
- Each learner will complete an additional 60 hours of off-site service learning in order to build a toolkit of community resources.
- A course attendance policy will be enforced (no more than 2 excused absences allowed).
To be considered for this scholarship, candidates must:
1. Meet the eligibility criteria noted within this application on the next screen
2. Commit to active participation in all program components
3. Attend weekly live distance learning scheduled events
4. Complete all reading and homework assignments
5. Complete 60 hours of service learning experiences within their local community.
6. Identify a 'dedicated supporter' (pharmacist, manager, or owner) who will actively support the candidate’s participation in the program for the full 16 weeks and beyond.
7. Be willing to provide feedback to assist in outcomes measurement and reporting related to the impact the program has on the profession of pharmacy and all communities served.

Application Criteria
Please ensure you meet all eligibility criteria before submitting your application.

The following list includes all eligibility criteria for the training course:
- Hold an active (unexpired) nationally certified pharmacy technician credential issued by PTCB or ExCPT (submission of this credential is required)
- Active employment at an independent community pharmacy (and an ability to maintain active employment throughout the length of the program)
- Provide a verifiable NCPDP number from the CHW applicant’s primary pharmacy practice site
- Submit an active email address for a “dedicated supporter” (pharmacist, pharmacy manager, or owner) who will engage with the CHW candidate and provide resources and support for the candidate for the entire length of the program, including any post-reporting or inquiries from program administrators (“dedicated supporters” will be emailed a letter of attestation requiring review and signature)
- Provide any required contact and demographic information
- Agree to receive program emails, texts, and other communications to ensure ongoing engagement with the program to assist in continuous improvement of the program and amplification of the impact that the program has in local communities
- Participate in ongoing reporting of outcomes and benefits
- Have access to a computer, tablet, or other device with a camera, microphone, speakers, and internet access to facilitate active engagement during live sessions
- Commit to completing all course requirements

Disclosure Statement

Financial support for this program is provided through an unrestricted educational grant from McKesson. Affiliation with McKesson (and/or Health Mart) is not required to be considered for a scholarship.

Disclaimer

CEimpact will process all applications received and internally review to determine baseline eligibility. To prioritize access to the financially-supported CHW training, additional criteria will be utilized at the discretion of CEimpact to award scholarships.

Candidate Information

Enter your contact information below.
Candidate's Name*

First NameLast Name
Candidate's Email*
example@example.com
Candidate's Personal Mobile Number*
Please enter a valid phone number. Your personal number will not be shared and will be used for the sole purpose of communication related to this course.
Candidate's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Information

Enter your employer's information below.
Name of Pharmacy or Company*
Employer's NCPDP Provider Identification Numbers (primary practice site)*
What is an NCPDP Provider ID Number? The NCPDP Provider ID is a seven-digit numbering system that is assigned to every licensed pharmacy and qualified non-pharmacy dispensing sites (NDPS) in the U.S.
Employer's Phone Number*
Please enter a valid phone number.
Employer's Address (primary practice site)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dedicated Supporter
Each candidate is required to submit an active email address for a “dedicated supporter” (pharmacist, pharmacy manager, or owner) at their primary practice site who will engage with the CHW candidate and provide resources and support for the candidate for the entire length of the program. Including, but not limited to, any post-reporting or inquiries from program administrators.

Each “dedicated supporter” will be emailed a letter of attestation requiring review and signature. This completed document is required to be considered for a full scholarship.

Candidates should discuss the specifics of this training course with their chosen “dedicated supporter” prior to completing this application. Again, if a "dedicated supporter" does not complete the online attestation form, the associated applicant will not be considered to receive scholarship funds.
Dedicated Supporter Information

Enter your Dedicated Supporter's information below. After entering their information, we highly encourage you to meet with them to reinforce the importance of completing the online attestation form they will receive pledging full support on your behalf.
Dedicated Supporter's Name*

First NameLast Name
Dedicated Supporter's Email*
example@example.com
Dedicated Supporter's Practice Role*

PharmacistManagerPharmacist in ChargeCompany CEOOwnerOther (please specify)

Required Materials
The following materials are required for this course:
- Computer, tablet, or other device in good working order
- Camera (embedded within the device is acceptable)
- Microphone (embedded within the device is acceptable)
- Speakers (embedded within the device is acceptable)
- Reliable Internet Access

Required Textbook
The following textbook is required for this course:

Foundations for Community Health Workers; Second Edition (2016), Jossey-Bass Publications; John Wiley and Sons, Inc.

All costs associated with obtaining a copy of the textbook are covered by the scholarship funds.
Please select your preferred type of textbook:*

Printed Format (a paperback printed book)Electronic Format (readable through the Kindle app on your computer or mobile device)

Printed Format
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.

Enter the email address where your electronic textbook will be delivered*
example@example.com
Enter the mailing address where your paper textbook will be delivered*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next, you will be asked to upload a copy of your nationally recognized pharmacy technician certification (from PTCB or ExCPT). Ensure the file you upload shows that your certification is active (not expired). PLEASE NOTE: National certification (PTCB/ExCPT) is different than being registered with your state board. Be sure you have a certificate from one of the national certification organizations noted here.
Please upload a copy of your nationally recognized pharmacy technician certification (from PTCB or ExCPT).*

If possible, please label your uploaded file with your name (for example, the file name should be "Last Name, First Name"). This will assist CEimpact during the review process.
Cancelof

Please provide a brief, personal statement about why you want to complete the CHW training. Why do you want to be considered for scholarship funds? How will you use this training in your community? Please provide 3-5 sentences below.*
Please provide a personal interest statement. Make your application shine from all the others.

Candidate Attestation
To meet the requirements of the CHW scholarship, I agree to:
- Attend all course meeting times as scheduled. Meetings are held virtually via an online meeting platform every Tuesday evening from 6PM-8PM CST.
- Actively participate in virtual classroom discussions and activities.
- Complete all course work and activities as assigned (anticipate 2-3 hours of homework per week, including course readings).
- Complete 60 hours of service-learning (experiential) activities.
  - **Please note, each individual learner (in collaboration with their practice site and dedicated supporter) is responsible for identifying their service-learning opportunities and coordinating all associated logistics. Course facilitators and instructors will provide guidance for identifying service-learning opportunities, but learners are ultimately responsible for executing all tasks associated with service-learning.
- Create a Resource Guide to support my future work as a CHW.
  - **Please note, guidance for creating a Resource Guide will be provided as part of the course.
State CHW Certification Attestation*
Should be Empty:

Community Health Worker Training Scholarship Application

Application Criteria

Candidate Information

Employer Information

Dedicated Supporter

Dedicated Supporter Information

Required Materials

Required Textbook

Candidate Attestation