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Thank you for looking to contact and/or partner with the National Association of Community Health Workers (NACHW)!
This contact form serves as the primary way to begin working with NACHW or getting a question answered! If you would like NACHW to present at an event, please visit this form: https://form.jotform.com/232218645768162. Please allow us up-to 5 business days to respond to your request (please allow 10 business days if it is a policy review request). Thank you and we look forward to assisting you!
Name
*
First Name
Last Name
Email
*
example@example.com
Are you contacting NACHW about becoming a member or looking for assistance signing into our membership portal?
*
Yes
No
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Organization Name
*
Organizational Website (n/a if not applicable)
What is the specialization of your organization? (If applicable)
Substance Use Recovery
Advocacy and Policy
Aging & Older Adult Health
Behavioral health (substance abuse, suicide, mental health, etc.)
Cancer
Children’s Health/Pediatrics
Community Violence Prevention
Dental/Oral Health
Diabetes
Emergency Preparedness
Environmental Justice and Climate Change
Financial and Healthcare Access and Navigation
Health Literacy or HealthCare Literacy
Healthy Housing (e.g. safe home environment, clean water, lead removal, air purification etc.)
Heart Health
HIV-AIDS/STIs
Infectious diseases (COVID-19, RSV, influenza, etc.)
Justice, equity, diversity, inclusion
LGBTQI
Prenatal/Maternal/Infant health
Men’s Health
Mental Health (e.g. depression, healthy coping skills,
Nutrition
Racial Health Equity
Antiracism, antidiscrimination, and addressing structural violence
Re-entry/Returning Citizens
Refugee and Migrant Health
Social Welfare/Economic Opportunity
Women's Health
Other
Phone Number
-
Area Code
Phone Number
Country
*
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State or territory:
*
Organization Type
*
Please Select
Community based organization
Local or state health department
Non-profit
Health center or hospital
• CHW Network: a state/regional organization, association, or coalition with 50%+ CHW leadership & membership, whose mission/activities focus on CHW training, workforce development, mentoring, member mobilization, cross-sector networking, and advocacy
• Non-profit community-based organization (CBO) that offers culturally-centered/specific services Other non-profit
• Local or state health department
• Other governmental department, agency, organization
• Education Service District or school (grades K-12)
• College or university
• Clinic or hospital or other organization where licensed medical professionals provide health services
• Federally Qualified Health Center (FQHC) Rural Health Clinic (RHC)
• Health insurance/payer, health plan, and/or payer-provider organization Consulting company or technical assistance provider Unemployed/looking for work
• Tribal organization
• Other:
What is the scope of this organization's services or activities?
*
Local
Statewide
Regional
National
International
Unsure
How did you hear about NACHW? (Please check all that apply)
NACHW’s social media
NACHW’s website
A NACHW webinar or event
I saw NACHW present at someone else’s event.
A friend or co-worker
My employer
My local or state CHW Network (Association or Coalition)
National or Local News Media or Publications
Other
Community Health Workers (CHWs) is an umbrella term including Promotor/a de Salud, Community Health Representative (CHR), tribal (CHW)
I am a
*
CHW
Ally
Type of membership
Individual Member
Not a member
I am part of Organizational member
I am part of the Network Member
I am a member at another network/association
I would like to (check all that apply)
*
Request a letter of support from NACHW
Ask NACHW to review or collaborate on a policy or advocacy issue.
Contract with NACHW for technical assistance for my organization.
Request technical assistance for my state, local, or regional CHW Network or Association
Invite NACHW to speak at an event.
Request to have my organization added to NACHW’s training webpage.
Feature or quote NACHW in an article, paper, blog post, etc.
Ask a question about membership or contact membership support.
Get in touch with NACHW about something not listed here (please explain)
Provide feedback to NACHW
Become a member
Interest in sponsoring NACHW or inviting NACHW to apply for a grant
Apply to have a CHW Network page on CHW Connector
Please explain further:
Submit
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Letter of Support
Thank you for reaching out to NACHW for a Letter of Support!
What is the due date for the Letter of Support (LOS)
*
-
Month
-
Day
Year
Date
Please upload any relevant documents and/or a project description for the project or initiative.
*
Browse Files
Cancel
of
If not included in the project description, please describe how your organization is committed to the CHW workforce and/or how you partner with CHWs.
What, if any, role will NACHW have in the project we are submitting a LOS for
*
NACHW's approaches are listed below. Please select all the approaches that align with your organization or project objective (if applicable)
Amplify the unique identity, qualities, competencies, expertise and voice of authentic Community Health Workers
Articulate CHW leadership, capacity and vision
Ally with individuals and organizations who share our values and support our strategic priorities
Advance innovations in CHW workforce development, integration and career pathways
Advocate for sustainable and equitable policies that respect, protect and partner with CHWs and our Networks and Associations.
N/A none of the above
NACHW’s values are listed below. Please select the values that are aligned with your own organization or project objective (select all that apply):
*
Self-empowerment: promoting self-actualization and self-advocacy among community health workers
Social justice & Equity: ensuring fair treatment, access, opportunity, advancement, and outcomes for individuals and communities
Self-determination: promoting the efforts of the community health workers, and the communities in which they work to create a shared vision and direction of the future
Dignity & Respect: building trusted relationships based on honoring the inherent value and contributions of every person
Unity: encouraging collaboration among community health workers to promote a common professional identity regardless of job title or work setting
Integrity: promoting and nurturing the authenticity and character of the community health worker profession and promoting the contributions made by the CHWs toward eliminating health disparities and advancing health equity
N/A none of the above
Would you like to meet to discuss the LOS and/or partnership?
*
Yes
No
Other
Please upload a draft of the Letter of Support
*
Browse Files
Cancel
of
Anything else we should know?
Submit
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Policy Request
Please fill out this form if you would like to request input from NACHW on a policy, paper, position statement, or another policy and advocacy-related issue, project, or initiative. You can also use this form to request NACHW’s participation in a CHW policy-related workgroup, roundtable, or another CHW policy-related event. Please note the following: 1. NACHW’s current capacity allows us to take on a limited number of requests. We require a minimum of two weeks to process and respond to most requests. 2. We will prioritize and make every effort to work on requests from NACHW members, community-based organizations (CBOs), and CHW Networks (defined as state/regional organizations, associations, or coalitions comprised of 50% or more of CHWs in leadership and membership, and whose mission and activities focus on CHW training, workforce development, mentoring, member mobilization, and cross- sector networking, and advocacy). 3. We may follow up with additional questions. Requests are considered incomplete until we receive all information necessary to process your request. 4. Please keep in mind that NACHW does not endorse individual training programs, curricula, or candidates for any political office. 5. NACHW promotes CHW leadership and we are committed to transparency and collaboration with our members. In some cases, NACHW may engage our members in a particular state or region regarding the information we receive through this form.
Are you authorized to complete this form on behalf of your organization?
*
Yes
No
Unsure
Brief summary of reason for request * List any additional organizations involved and their roles, identify who is leading the work, and describe desired outcomes of the work related to this request.
*
Requested due date for NACHW's response or input *We require a minimum of 10 business days to process your request and prepare a response or contribution (if applicable).
*
-
Month
-
Day
Year
Date
Which of the following does your request involve? Please prioritize your responses.
*
Most important
Important
Neutral
Less Important
Not applicable
Endorsement (NACHW "signs-- on," approves use of NACHW logo)
Contribution and/or co-authorship (NACHW edits, provides input, will be listed as a contributing co-author)
Advisement (NACHW offers general recommendations)
Promotion, awareness-raising, advocacy
Participation (NACHW participates in a meeting or committee, speaks att a webinar, conference, etc..)
Please list and provide detail about the specific tasks requested.
If NACHW responds as requested, what will happen to the information we provide? Who will do what? When?
*
Please describe how CHWs were involved in the work related to this request. How were CHWs involved in the development of the policy/document to be reviewed (if applicable)? Please include how many CHWs and how many allies were involved. Provide your best guess if you are unsure. Type "n/a" if this does not apply.
*
If there is a CHW Network* in your geographic area, provide the name of that organization and describe how you have involved/coordinated/partnered with them in the work related to this request. Type n/a if this does not apply. *NACHW uses the term CHW Network to describe a state/regional organization, association, or coalition comprised of 50% or more of CHWs in leadership and membership, and whose mission and activities focus on CHW training, workforce development, mentoring, member mobilization, and cross- sector networking, and advocacy.
*
Please provide a point of contact who could potentially answer questions from NACHW members in your geographic area about the work related to this request.
*
First Name
Last Name
Email
*
example@example.com
If you requested that NACHW review a specific policy/document, please upload the current version of the policy/document here. This question is required if applicable.
*
Number of pages of content be reviewed by NACHW: * Do not include references. Enter 0 if this question does not apply.
*
Please upload any additional materials or information that will help us understand the context of your request. For example, if you asked NACHW to join a work group, please upload any available content, such as the participant roster, work group charter, project scope of work or purpose statement, etc.
*
Browse Files
Cancel
of
Please discuss this request with your organization. NACHW welcomes responses from individuals who are authorized to complete this form on behalf of the organization identified in the request. For questions, contact akuzma@hria.org.
Submit
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Contracting with NACHW/NACHW providing technical assistance for my organization.
Thank you for your interest in NACHW's technical assistance! We look forward to working with you and/or introducing you to one of our partners.
How would you describe the area of technical assistance you are interested in receiving? (Check all that apply):
*
Hiring and/or Recruitment of CHWs
Supervision and/or career pathways for CHWs
Developing CHW Workforce Studies.
Increasing partnership with CHW Networks and CBOs
Leadership development for CHWs
CHW sustainable financing
CHW policy and advocacy
Research and evaluation
Creating and disseminating chronic disease and/or infectious disease materials for CHWs
Other
NACHW's approaches are listed below. Please select all the approaches that apply to NACHW's role in the project or initiative (if applicable)
*
Amplify the unique identity, qualities, competencies, expertise and voice of authentic Community Health Workers
Articulate CHW leadership, capacity and vision
Ally with individuals and organizations who share our values and support our strategic priorities
Advance innovations in CHW workforce development, integration and career pathways
Advocate for sustainable and equitable policies that respect, protect and partner with CHWs and our Networks and Associations.
N/A, none of the above
NACHW’s values are listed below. Please select the values that are aligned with your own organization or project objective (select all that apply):
*
Self-empowerment: promoting self-actualization and self-advocacy among community health workers
Social justice & Equity: ensuring fair treatment, access, opportunity, advancement, and outcomes for individuals and communities
Self-determination: promoting the efforts of the community health workers, and the communities in which they work to create a shared vision and direction of the future
Dignity & Respect: building trusted relationships based on honoring the inherent value and contributions of every person
Unity: encouraging collaboration among community health workers to promote a common professional identity regardless of job title or work setting
Integrity: promoting and nurturing the authenticity and character of the community health worker profession and promoting the contributions made by the CHWs toward eliminating health disparities and advancing health equity
N/A, none of the above
How does/has your organization partnered with CHWs?
Anything else we should know?
Submit
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Receiving technical assistance as a CHW Network.
NACHW is currently building out our technical assistance for CHW Networks, but please describe how we can assist and we will do our best to assist and/or introduce you to our partners.
I am interested in having my CHW Network receiving the following supports:
Being connected to other CHW Networks
Help using the NACHW Document Resource Center
Connections to our board and founders
Please describe any other training or technical assistance you are interested in having NACHW provide:
*
Submit
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Invite NACHW to speak at an event.
NACHW has a separate form for speaking engagements! Please complete this form: https://form.jotform.com/232218645768162
Submit
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Feature or quote NACHW in an article, paper, blog post, etc.
Thank you for your interest in featuring NACHW in your publication! Please answer the following questions
What is the subject of the article?
*
What is the name of the publication?
*
When is the due date for the quote and/or interview?
*
-
Month
-
Day
Year
Date
Anything else we should know?
Submit
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Request to have my organization added to NACHW’s training webpage.
Thank you for your interest in having NACHW add your organization to NACHW’s Training Site webpage: https://nachw.org/membership/chw-networks-and-certification-programs/
I am authorized to add my organization and contact information to the NACHW site:
*
Yes
No
Write your organization’s name as you would like it to appear on the webpage:
*
Add a link (if applicable) to the organization’s website:
*
Add any additional contact information you would like included on the webpage:
Submit
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Ask a question about membership or contact membership support
Please refer to https://nachw.org/membership/ to find information on membership benefits or information on how to sign-up for membership. Thank you for being our member!
How can we assist you?
*
Need assistance with logging into memberclicks (NACHW’s membership platform)
Would like to request my receipt for membership.
Would like to place a bulk order for membership.
Need clarification or have a question about a membership benefit
Other
Which problem are you are having with logging in?
Can't remember my username
Can't remember my password
Can't remember if I am a member
Other
Please describe the question you have about membership:
Submit
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Provide feedback to NACHW
Thank you for your willingness to provide feedback to NACHW. We encourage any and all feedback to unify voices and strengthen the Community Health Worker workforce and communities toward achieving health, equity, and social justice.
NACHW’s values are listed below. Please select the values that you feel NACHW demonstrates an explicit commitment (select all that apply):
*
Self-empowerment: promoting self-actualization and self-advocacy among community health workers
Social justice & Equity: ensuring fair treatment, access, opportunity, advancement, and outcomes for individuals and communities
Self-determination: promoting the efforts of the community health workers, and the communities in which they work to create a shared vision and direction of the future
Dignity & Respect: building trusted relationships based on honoring the inherent value and contributions of every person
Unity: encouraging collaboration among community health workers to promote a common professional identity regardless of job title or work setting
Integrity: promoting and nurturing the authenticity and character of the community health worker profession and promoting the contributions made by the CHWs toward eliminating health disparities and advancing health equity
N/A none of the above
Overall, how would you rate NACHW's impact in the CHW profession?
No impact
Negative impact
Minor positive impact
Moderate positive impact
Significant positive impact
Overall, how comfortable do you feel approaching NACHW if a problem arises?
Not at all comfortable
Somewhat comfortable
Comfortable
Very comfortable
How responsive is the NACHW team?
Not at all responsive
Somewhat responsive
Responsive
Very Responsive
How well does NACHW understand the social, cultural, or socioeconomic factors that affect your work?
Limited understanding
Minor understanding
Moderate understanding
Significant understanding
Please rate the extent to which you agree or disagree with the following statement: Overall, NACHW demonstrates an explicit commitment to racial and health equity.
Strongly disagree
Disagree
Agree
Strongly Agree
Any feedback that you would like to provide:
*
Would you like to have a NACHW staff person follow-up with you on this feedback?
*
Yes
No
Other
Submit
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Interest in sponsoring NACHW or inviting NACHW to apply for a grant
Thank you for considering NACHW for your sponsorship or funding! We look forward to meeting with you.
Please describe the general area of the grant/funding (ex. advocacy, CHW sustainability, chronic disease specific work etc.)
*
Is there a specific due date for the grant/funding/sponsorship? (Put N/A if none)
*
Would you like to have a NACHW staff member follow-up to schedule a meeting?
Yes
No
Other
NACHW’s values are listed below. Please select the values that are aligned with the funding or grant's mission (select all that apply):
*
Self-empowerment: promoting self-actualization and self-advocacy among community health workers
Social justice & Equity: ensuring fair treatment, access, opportunity, advancement, and outcomes for individuals and communities
Self-determination: promoting the efforts of the community health workers, and the communities in which they work to create a shared vision and direction of the future
Dignity & Respect: building trusted relationships based on honoring the inherent value and contributions of every person
Unity: encouraging collaboration among community health workers to promote a common professional identity regardless of job title or work setting
Integrity: promoting and nurturing the authenticity and character of the community health worker profession and promoting the contributions made by the CHWs toward eliminating health disparities and advancing health equity
N/A, none of the above
NACHW's approaches are listed below. Please select all the approaches that you believe this funding could support:
*
Amplify the unique identity, qualities, competencies, expertise and voice of authentic Community Health Workers
Articulate CHW leadership, capacity and vision
Ally with individuals and organizations who share our values and support our strategic priorities
Advance innovations in CHW workforce development, integration and career pathways
Advocate for sustainable and equitable policies that respect, protect and partner with CHWs and our Networks and Associations.
N/A, none of the above
Anything else we should know?
Submit
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Does your organization fit the following definition: NACHW defines CHW Networks as community-based organizations (including CHW Associations and Coalitions) with leadership and/or membership that is comprised of 50% or more of CHWs, and whose mission and activities focus on workforce development, mentoring, member mobilization, and advocacy.
*
Yes
No
Unsure
Please provide a description of the mission/vision of your CHW Network organization?
*
Which of the following activities does your CHW Network do?
*
CHW training - curriculum development
CHW training – facilitation
Policy & advocacy
CHW program management or operations
CHW program management or operations
Annual conference or other CHW convenings
CHW-related research
CHW program evaluation
CHW program data management
Member directory
CHW registry
Share community resources with CHWs
Share job opportunities with CHWs
CHW community of practice
Share self-care resources with CHWs
None of the above
Other
What is the percentage of CHWs on your board? (CHW board members/ All board members = %)
*
Who will be the contact for your CHW Network page?
*
First Name
Last Name
What will be the contact email for your CHW Network page?
*
example@example.com
Submit
Should be Empty: