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Workforce Development Program Screening Survey

Thank you for your interest in our medical training program! The information you provide in this survey will help us determine your eligibility. A response will be sent to the email address you provide in question 2.

A response is required for every question. Please answer the question that is being asked.

Please submit your survey before October 15, 2025.

Please note: All selected applicants must be able to pass a level 2 background screening.
1.Please enter your name.(Required.)
2.Please enter your email address and phone number.(Required.)
3.Which certification are you interested in?(Required.)
4.What are your primary reasons for pursuing this certification? (Select all that apply)(Required.)
5.How did you hear about our workforce development program?(Required.)
6.Do you currently work in the medical field?(Required.)
7.Do you have any previous experience in the medical or healthcare field? If yes, please describe.(Required.)
8.Are you currently employed?(Required.)
9.Are you able to provide proof of having a high school diploma or GED?(Required.)
10.Do you have any prior certifications or degrees? If yes, please list.(Required.)
11.Employment in the medical field typically requires passing a Level 2 Background screening. Are you able to pass a level 2 background screening?(Required.)
12.What are your long-term career goals in the healthcare field?(Required.)
13.Why do you believe you are a good candidate for this program?(Required.)
14.Do you currently face any of the following barriers to employment? (Check all that apply)(Required.)
15.Do you have reliable transportation to attend in-person training sessions?(Required.)
16.The training may include additional costs (e.g., school uniform, TB testing, and supplies) estimated at >$100. Do you have the resources to cover these costs?(Required.)