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Application for Maine DHHS CHW Steering Committee

Nominee Information

Please complete this form if you wish to nominate yourself to serve as a member of the Maine Department of Health & Human Services Community Health Worker Steering Committee. For questions or support with any part of the application, please contact Ben Hummel at benjamin.hummel@maine.gov. We will be in touch with you regarding your application once it is submitted. It may take several weeks for us to follow up.

1.Full Name(Required.)
2.Email Address(Required.)
3.Phone Number(Required.)
4.Agency/Organization(Required.)
5.Which race or ethnicity best describes you?(Required.)
6.Do you identify as a Community Health Worker?(Required.)
7.How many years have you worked as a CHW?(Required.)
8.Do you supervise or manage a team of CHWs?(Required.)
9.How would you describe your work setting?(Required.)
10.What geographic area(s) of the state do you work in?(Required.)
11.Please briefly describe the community that you work with:(Required.)
12.Please provide a brief personal statement (4-6 sentences) on why you wish to join the Steering Committee and what experience you have:(Required.)
13.I have discussed this opportunity with my employer/supervisor and they support my involvement in the Committee:(Required.)
14.Describe any barriers that may prevent you from actively participating (you will still be considered, even if you list potential barriers):(Required.)