TNCHWA CHW Training Program Application

TNCHWA CHW Training Program Application

Please watch the video and answer the questions below to begin the application. Please note that if you are interested in completing the scholarship application, the link will appear in the "Thank You" note after you submit this application. Please email Brea.burke@tnchwa.org with any questions.
Youtube
How Many Weeks is the TNCHWA CHW Training Program?
How Many Competencies is the TNCHWA CHW Training Program aligned with?
There is an in-person/virtual training and field placement part of the program. What is the other part of the training program?

Eligibility Attestation
1. I am 18 years of age or older.
2. I understand the training must be completed within the required timeframe (approximately 8-10 weeks).
3. I am able to actively participate, attend sessions, and complete all required modules and assignments.
4. I understand that I will need technology to complete the program (internet, laptop, tablet or technology that has access to microphones and camera capabilities).
5. I understand I will need to complete a 160-hour field placement and TNCHWA cannot guarantee placement.
6. I understand that the cost of this program is $1,200 per CHW. CHWs who are not participating in the training during paid working hours may be eligible for a scholarship; scholarship applications are available via a link provided once you complete this application.
6a. Please provide the email address for the individual or organization responsible for payment. If you will be applying for a scholarship, please enter "n/a", as we will collect more information later.
7. I have watched the orientation video and understand the requirements of completing the program.

Section 1: Applicant Information
1. Applicant Name

First NameMiddle NameLast Name
2. Preferred Name
3. Personal Email Address
example@example.com
4. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
5. Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
6. County of Residence
7. Are you currently employed?

Other
8. Current Employer/Organization (Please enter n/a if not employed)
9. Work Address if applicable

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Work Phone Number if applicable
Please enter a valid phone number.Format: (000) 000-0000.
11. Work Email if applicable
example@example.com
12.Tennessee Connection
13. English is my first language or language of choice
14. What is your preferred language?
Section 2: CHW Role & Field Placement
2.1 Are you a CHW?
2.2 Are you currently employed as a CHW?

Other
2.3 Which Work Setting have you served in or are interested in serving in (select all that apply)?
2.4 This program will require 160-hours of fieldwork. Are you currently employed in a role that could support your required fieldwork hours?
2.5 Field Placement Options (Check all that apply)
2.6 What field placement setting do your prefer? (check all that apply)

Other
2.7 What days and times are you available for field placement?

Other
Section 3: Interest & Experience
1. Why are you interested in becoming a Community Health Worker? (50-250 words)

0/250
2. Describe your experience working with communities, providing support services, or addressing Social Determinants of Health? (50-250 words)

0/250
3. How do you plan to use this training to support your community or the populations you serve?(50-250 words)

0/250
Section 4: Commitment & Readiness
4.1 Do you anticipate any challenges completing the training and field placement within the required timeframe of 8-10 weeks? (For details, see the orientation video.)
4.1a If yes, please explain.

0/250
4.2 Are you able to commit to the full duration of the training program? (For details, see the orientation video.)
4.2a If no, please explain.
Section 5: Agreements & Certification
Please review and confirm the following:
I agree to the terms and conditions and certify that the information provided in this application is true and complete to the best of my knowledge.
Certification Signature
Section 7: Demographic Information
Page Break
This information is collected for reporting, program improvement, and to ensure equitable access. It is confidential and will not impact your application. We want to ensure we are training a well-diverse group of CHWs to serve the great state of TN.
Ethnicity

Other
Race

Other
Gender Identity
Age Range
Should be Empty:

TNCHWA CHW Training Program Application

Eligibility Attestation

Section 1: Applicant Information

Section 2: CHW Role & Field Placement

Section 3: Interest & Experience

Section 4: Commitment & Readiness

Section 5: Agreements & Certification

Section 7: Demographic Information

This information is collected for reporting, program improvement, and to ensure equitable access. It is confidential and will not impact your application. We want to ensure we are training a well-diverse group of CHWs to serve the great state of TN.