CHWAR Community Health Worker Student Training Application Survey

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* 1. Please complete the following contact information:

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Primary Phone:

Alternative Phone:

Email Address:

Emergency Contact Name:

Emergency Contact Phone #:

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* 2. What is the highest level of education you have completed?

Less than high school degree

High school degree or equivalent (i.e., GED)

Some college but no degree

Associates degree (2-year)

Bachelor's degree (4-year)

Graduate degree

Other (please specify)

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* 3. What is your age?

18-24

25-34

35-44

45-54

55-64

65 or over

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* 4. Are you of Hispanic, Latino, or of Spanish origin?

Yes

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* 5. How would you describe yourself?

American Indian or Alaskan Native

Asian or Asian American

Black or African American

Native Hawaiian or other Pacific Islander

White or Caucasian

Multiple ethnicity/Other (please specify)

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* 6. What is your level of English fluency?

Fluent English speaker

Limited English speaker

English is not my preferred language

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* 7. Do you speak any other languages?

	Fluent speaker	Intermediate speaker	Do not speak
Spanish	Spanish Fluent speaker	Spanish Intermediate speaker	Spanish Do not speak

Other (please specify)

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* 8. What is your gender identity?

Man

Non-binary

Woman

Not specified above, please specify:

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* 9. Have you completed any type of CHW Training?

Yes

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* 10. Please list any other trainings or certifications you have taken:

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* 11. WORK EXPERIENCE (if yes, enter information below)

Yes

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* 12. Work Experience 1

Where:

Position Title:

Start Date of Employment:

End Date of Employment:

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* 13. Work Experience 2

Where:

Position Title:

Start Date of Employment:

End Date of Employment:

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* 14. Work Experience 3

Where:

Position Title:

Start Date of Employment:

End Date of Employment:

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* 15. Do you have experience with any of the following work fields? (Check all that apply)

Mental health

Chronic health conditions

Patient direct care services

Addiction/substance abuse

Prenatal care/children

Street outreach

COVID 19

CHWAR Community Health Worker Student Training Application

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* 1. Please complete the following contact information:

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* 2. What is the highest level of education you have completed?

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* 3. What is your age?

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* 4. Are you of Hispanic, Latino, or of Spanish origin?

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* 5. How would you describe yourself?

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* 6. What is your level of English fluency?

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* 7. Do you speak any other languages?

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* 8. What is your gender identity?

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* 9. Have you completed any type of CHW Training?

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* 10. Please list any other trainings or certifications you have taken:

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* 11. WORK EXPERIENCE (if yes, enter information below)

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* 12. Work Experience 1

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* 13. Work Experience 2

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* 14. Work Experience 3

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* 15. Do you have experience with any of the following work fields? (Check all that apply)

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* 16. Please describe any special interests and/or other volunteer work experience:

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* 17. Why do you want to become a Community Health Worker?

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* 18. What experience do you have with advocating for patients/clients/family members with health related or other services?

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* 19. How did you hear about our CHW training?