Group Facilitation Skills for CHWs & Allies - Training Registration

MCD’s HRSA Community Health Worker Training Program (CHWTP) covers the fees for this training.

HRSA requires us to collect some demographic and employment information from our training participants.

Note: While we ask for identifying information for grant reporting purposes, no names or identifying information will be shared or included in any publications or presentations based on the data collected.

Question Title

* 1. Which do you identify as?

Community Health Worker (CHW)

CHW Ally

CHW Supervisor

Other (please specify)

Question Title

* 2. Basic Personal Information

First Name

Last Name

Preferred name

Phone Number

Home Zip Code

Year of Birth

Question Title

* 3. Mailing Information

Address

City/Town

State

Zip Code

Question Title

* 4. Current Gender Identity (Select all that apply)

Male

Female

Transgender

Non-Binary

Prefer not to say

Other gender identity/ identity not listed

Question Title

* 5. Are you of Hispanic/ Latin Origin?

Yes

Prefer not to answer

Question Title

* 6. Race

American Indian or Alaska Native

Asian

Pacific Islander

Latino

Black, not of Latino Origin

White, not of Latino Origin

Prefer not to answer

Another race (please specify)

Question Title

* 7. Highest Level of Education

Elementary/ Middle School (Up to 8th Grade)

High School Diploma/ GED

Some College (no degree)

Associate's Degree

Bachelor's Degree

Master's Degree

Professional or PhD Degree

Question Title

* 8. Are you a United States citizen or Permanent Resident (Green Card holder)?

Yes

Question Title

* 9. Are you currently in or have served in the United States military?

Yes, Active Duty

Yes, Reserved Duty

Yes, Military Veteran

No, I have never served in the military

Prefer not to say

Question Title

* 10. Have you experienced any of the following:

Were or currently are homeless

Were or currently are in the foster care system

Were eligible for the Federal Free and Reduced Lunch Program for two or more years

Have/had no parents or legal guardians who completed a bachelor’s degree

Were or currently are eligible for Federal Pell grants

Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child

I have not experienced any of the above

Prefer not to say

Question Title

* 11. Employment Status

Employed Full-Time

Employed Part-Time

Volunteering

No, Retired

No, Looking for Employment

Prefer not to say

Other (please specify)

Question Title

* 12. Please name the organization you currently work for.

Question Title

* 13. Physical Address of Organization

Street Address

City, State, Zip

Question Title

* 14. Please list any dietary, accessibility, or mobility needs.

Question Title

* 15. Is there anything else you would like us to know about you, needs or comments?

Thank you for registering for the Group Facilitation Skills for CHWs & Allies Training. We will reach out to you with further training details soon.

If you have any questions in the meantime, please contact Makara Pollard, Program Coordinator, at mpollard@mcd.org.