CHW Application Survey - Capital Region 2016-2017

Community Health Worker Career Pathways Program

Program Application and Eligibility Form

Thank you for your interest in the Community Health Worker Training Program. Please complete this on-line application and eligibility form. We will contact you regarding coming to Temple University Harrisburg for an information session.

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* 1. Today's Date

MM/DD/YYYY

Date

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* 2. Please provide contact information.

First Name

Last Name

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 3. What is your date of birth?

MM/YYYY

Date

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* 4. What is your gender?

Female

Male

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* 5. What is your race?

American Indian or Alaskan Native

Asian

Black or African-American

Native Hawaiian or other Pacific Islander

White

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* 6. What is your ethnicity? (Please select all that apply.)

Hispanic or Latino

Non-Hispanic/Non-Latino

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* 7. Please indicate if you identify with any of the following categories. (Please select all that apply.)

I have a rural background.

I am an underrepresented minority.

I do not have a Bachelor's Degree.

I consider myself economically disadvantaged.

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* 8. Please indicate if the following applies to you. (Please select all that apply.)

I am not a veteran.

I am on active military duty.

I am a reservist.

I am a veteran - prior service.

I am a veteran - retired.

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* 9. What are your goals after completion of the CHW Training Program? (Check all that apply.)

To get additional training

To get a degree

To continue with current employer

To work as a CHW in a rural community

To work as a CHW with particular populations

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* 10. How many people currently live in your household, including yourself?

1 person (myself only)

2 people

3 people

4 people

5 people

6 people

7 people

Other (please specify)

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* 11. Marital Status

Single

Living with Partner

Married

Divorced

Widowed

Separated

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* 12. Educational Attainment Level (check all that apply)

High School Diploma

GED

Vocational Training

Associate's Degree

Bachelor's Degree

Master's Degree

Other (please specify)