Community Health Worker Needs Assessment

Please complete this survey to help us understand your needs as a community health worker and the needs of your community. Thank you for your time!

If you have any questions about Triage Cancer or this survey, please email us at info@TriageCancer.org.

Question Title

* 1. Please provide your email address to join our newsletter and to be entered into a drawing for a $50 Gift Card (4 prizes available). You will be sent an email if you win.

Question Title

* 2. First Name

Question Title

* 3. Are you a: (check all that apply)

Volunteer Community Health Worker

Paid Community Health Worker

Certified or Professionally Trained Community Health Worker

Other (please specify)

Question Title

* 4. Which state are you located in?

Question Title

* 5. What is your current education level?

Some high school, no diploma

High school graduate, diploma or the equivalent (for example: GED)

Trade/technical/vocational training

Associate degree

Bachelor’s degree

Master’s degree

Professional degree

Doctorate degree

Question Title

* 6. What gender do you identify as?

Woman

Man

Transgender

Non-binary/non-conforming

A gender not listed here

Prefer not to respond

Question Title

* 7. Please specify your ethnicity.

White

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Perfer not to answer

Question Title

* 8. On average, how many community members do you reach a month?

Question Title

* 9. What language do you primarily use to communicate with your community members?

English

Spanish

Both English & Spanish

Other language (please specify)

Question Title

* 10. Do members of your community ask for help on how to keep working, or take time off, after a medical diagnosis?

Yes

N/A

Question Title

* 11. How comfortable are you answering community members' questions about the Americans with Disabilities Act (ADA)?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 12. How comfortable are you answering community members' questions about the Family and Medical Leave Act (FMLA)?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 13. Do members of your community express concern about sharing their diagnosis with others?

Yes

N/A

Question Title

* 14. How comfortable are you answering community members' questions about their options to share their diagnosis with others?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 15. Do your community members ask for guidance on health insurance options?

Yes

N/A

Question Title

* 16. How comfortable are you answering community members' questions about health insurance options?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 17. Do your community members ask for help to pay for medical care?

Yes

N/A

Question Title

* 18. How comfortable are you answering community members' questions about how to pay for medical care?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 19. If a community member is worried about finances, what is usually your first suggestion?

Apply for financial assistance

Review health insurance policy

Start a crowdfunding campaign (e.g., GoFundMe)

Other (please specify)

Question Title

* 20. Do members of your community ask for help paying for preventative services (e.g., immunizations, cancer screenings)?

Yes

N/A

Question Title

* 21. How comfortable are you answering community members' questions about paying for preventative services (e.g., immunizations, cancer screenings)?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 22. Do your community members ask for help to replace lost income if they need time off from work for their health (e.g., disability Insurance)?

Yes

N/A

Question Title

* 23. How comfortable are you answering community members' questions about disability insurance?

Very Comfortable

Comfortable

Somewhat Comfortable

Not Comfortable

Question Title

* 24. Would you be interested in any of the following opportunities? Check all that apply. (If yes, please make sure to provide your email above.)

Training for Community Health Workers on work and disability insurance.

Training for Community Health Workers on health insurance.

Partnering with Triage Cancer to offer a community-based educational event on work, disability, & health insurance.

Participating in a focus group/interview to help us learn more about the needs of your communities. (Participants would receive a $100 gift card)

None, I have all of the training I need.

Question Title

* 25. Is there anything else you think Triage Cancer should know about the issues your community members are facing?

Question Title

* 26. What resources do you find most helpful for your work?

Question Title

* 27. If you attended a presentation or event with Triage Cancer, please indicate the name of the event. (e.g. LLS Conference, Insurance & Finance Intensive, NASW Conference)