Healthy Aging Partnerships in Prevention Initiative

Ambassador Train the Trainer Course Online Application

Representatives of community-based organizations serving African American and Latino Adults age 50 and over in South Los Angeles are invited to apply for this free, two-day Healthy Aging and Clinical Prevention Services Train the Trainer Course.

The purpose of the course is to --
     A. Enhance knowledge and skills to conduct community education workshops on the role of clinical preventive services
         (CPS) in preserving health and reducing premature disability and death;
     B. Foster understanding of how to partner with community clinics to increase awareness and use of CPS;
     C. Enable CBOs to sustain use of CPS by the African American and Latino adults age 50+ served by the organization
          through evidence based interventions

Priority clinical preventive services for this project are—
     • Influenza vaccinations (flu shots)
     • Pneumococcal vaccinations (pneumonia shots)
     • Cholesterol screening
     • Colon cancer screening
     • Breast cancer screening (e.g., mammograms)
     • Cervical cancer screening (e.g., Pap smears)

Course participants are eligible to receive a stipend upon completion of the two day course and conducting a community workshop applying knowledge and skills learned in the course.

Organizations whose representatives have completed the course are eligible to apply to the HAPPI Small Grant Program to conduct a pilot project in collaboration with clinical preventive service providers and other partners to promote use of CPS by African American and Latino adults age 50 plus.

Eligibility
The course is open to representatives of community organizations serving African American and Latino Adults age 50 and over in South Los Angeles. Representatives must be staff of the organization who commit to complete the two-day training session and conduct a community education workshop to complete the course. Space is limited and provided on a first come, first serve basis to applicants who meet the eligibility criteria for participation.

The Application
Please complete the following application. Applicants are required to obtain a signed Memorandum of Understanding from their supervisor affirming permission to participate and fulfill requirements to complete the course. You will be asked to provide the name and contact information of your supervisor in this application.

Question Title

Please provide the following information. Applicants accepted into the course will receive a confirmation email, so please provide a current email address that you check regularly.

Your name:

Title/Role:

Organization:

Address:

City:

Zip:

Phone:

Fax:

Email:

Question Title

Do you have any specific meeting needs? (i.e wheelchair accessibility, large print materials, dietary restrictions, etc.)

Yes

If yes, what accommodation is needed?

Question Title

The HAPPI Ambassador Train the Trainer Course is a two day course. Attendance on both days is mandatory for participation. Two sessions are offered (Session A and Session B). Please select your preferred course session date and location. Rank session preference by clicking on the drop down icon and selecting "1" for your first preference and selecting "2" for your second preference. Seating capacity is limited to 20 persons per session however we will try to place you in your preferred session.

Session A: ____

Friday, April 15 8:30am – 3:00pm and Friday, April 29 8:30am – 12:30pm

Location: Martin Luther King Center for Public Health, 11833 S Wilmington Avenue, Los Angeles, CA 90059

Session B: _____

Tuesday, May 10 8:30am – 3:00pm and Tuesday, May 17 8:30am – 12:30pm

Location: Martin Luther King, Jr. Outpatient Center, Hudson Auditorium, 12021 S. Wilmington Avenue, Los Angeles, Ca 90059

Question Title

Please complete the following checklist to be sure you understand the course requirements:

I will plan and conduct a Healthy Aging and CPS community education workshop for members, clients, partners, or volunteers of my organization or community partners within 6 weeks following day 2 of the course.

Yes

Question Title

If notified I have been accepted into the course, I will complete and submit the MOU prior to the first day of the course

Yes

Question Title

My supervisor will support my participation in the 2-day training and conducting my community workshop.

Yes

Question Title

If you answered "Yes" to the previous question, please complete the fields below and supervisor's name and contact information. (NOTE: You cannot identify yourself as the supervisor. If you are the CEO, Executive Director, or lead person of your organization, you must identify organization leader, e.g., Board Chair to whom you report

Name

Title

Phone

Question Title

After acceptance into the course, if I cannot meet all course requirements, I will notify HAPPI project staff immediately.

Yes

Question Title

Please tell us about yourself and your organization. This information will help us to identify and meet your training needs. Your answers to these questions will not be used to determine course eligibility.

South Los Angeles

Inglewood

Hawthorne

Other (please specify)

Question Title

How would you describe your organization? (Please check all that apply)

501(c)3 status non-profit

Community-based or grassroots

Private or incorporated small business (i.e. beauty salon or barber ship, independent pharmacy, etc.)

Clinic, or other health service provider

Other (please specify)

Question Title

What is the focus of your organization? (Please check all that apply)

Advocacy/ Public policy

Health care services

Health outreach and education

Social services

Other (please specify)

Question Title

What are the target populations for your organization or program? (Please check all that apply)

Adults age 50 and older

Intergenerational - all ages including adults age 50 and older

African American

American Indian

Asian-Pacific Islander

Latino

Non-Latino white

Spanish monolingual

Low-income

Immigrant

Homeless

Other (please specify)

Question Title

What is the size of your organization, including full- and part-time staff? (Please check one)

1-5 staff

6-10 staff

11-20 staff

More than 20 staff

Question Title

What is your organization’s annual budget? (Please check one)

Less than $100,000 per year

$100,000 to $250,000 per year

$250,000 to $500,000 per year

$500,000 to $1,000,000 per year

More than $1,000,000 per year

Question Title

Do you have experience with the following?
I have trained community groups (check one):

many times

a few times

no experience

I have experience with health education and promotion on the following topics:

Question Title

I have experience with clinical preventive services education, promotion, or program planning

Yes

Question Title

If you answered yes to Question 12, which clinical preventive services? (Check all that apply)

Influenza vaccinations (flu shots)

Pneumococcal vaccinations (pneumonia shots)

Cholesterol screening

Colon cancer screening

Breast cancer screening (e.g., mammograms)

Cervical cancer screening (e.g., Pap smears)

Question Title

Please provide the following information. Applicants accepted into the course will receive a confirmation email, so please provide a current email address that you check regularly.

Question Title

Do you have any specific meeting needs? (i.e wheelchair accessibility, large print materials, dietary restrictions, etc.)

Question Title

Question Title

Please complete the following checklist to be sure you understand the course requirements:I will plan and conduct a Healthy Aging and CPS community education workshop for members, clients, partners, or volunteers of my organization or community partners within 6 weeks following day 2 of the course.

Question Title

If notified I have been accepted into the course, I will complete and submit the MOU prior to the first day of the course

Question Title

My supervisor will support my participation in the 2-day training and conducting my community workshop.

Question Title

Question Title

After acceptance into the course, if I cannot meet all course requirements, I will notify HAPPI project staff immediately.

Question Title

Please tell us about yourself and your organization. This information will help us to identify and meet your training needs. Your answers to these questions will not be used to determine course eligibility.

Question Title

How would you describe your organization? (Please check all that apply)

Question Title

What is the focus of your organization? (Please check all that apply)

Question Title

What are the target populations for your organization or program? (Please check all that apply)

Question Title

What is the size of your organization, including full- and part-time staff? (Please check one)

Question Title

What is your organization’s annual budget? (Please check one)

Question Title

Do you have experience with the following? I have trained community groups (check one):

Question Title

I have experience with clinical preventive services education, promotion, or program planning

Question Title

If you answered yes to Question 12, which clinical preventive services? (Check all that apply)

Do you have experience with the following?
I have trained community groups (check one):