Hello / Aloha / Talofa lava / Malo 'e lelei:

Due to HRSA (our funder) requirements, all Community Health Workers and other type of outreach workers in the CHW Workforce Collaborative are required to complete this CHW Profile Form. This form only needs to be completed once per worker.

Your information will be kept anonymous and confidential and will not be shared with your employer.

AAPCHO will use this information to demonstrate the diversity of our health care workforce across all local partners nationally; and HRSA intends to use this information to understand how job opportunities were created through government funding from their agency.

If you have any questions or concerns, please contact Nashia Choudhury at nchoudhury@aapcho.org and Vanessa Wan at vwan@aapcho.org. 

Thank you / Mahalo / Fa'afetai lava/ Malo aupito!

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* 1. We collect the information that follows in this form with a unique identifier number that only you and your employer know so that your responses to our questions will not be associated with your name or any information that can be used to identify you. This keeps your responses to this survey anonymous and confidential.

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* 2. Are you completing this form for the CHW 1 grant, CHW 2 grant, or both grants?

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* 3. Partner Organization Name

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* 4. Please provide the unique identifier assigned to you as a community health worker or other type of outreach worker (by your employer).

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* 5. What is the name of your employer (the community-based organization and/or health center supported by AAPCHO) that you work for as a community health worker or other type of outreach worker?

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* 6. We're going to start by asking you some questions about yourself. Your responses will not be associated with your name or any information that can be used to identify you. Please provide the 5-digit ZIP code where you live.

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* 7. Do you own the home where you live (check one)?

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* 8. How many people live in your household, including yourself (check one)?

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* 9. Do you live in the same community where you will work for this job as a community health worker or other type of outreach worker (check one)?

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* 10. Please list all the ZIP codes where you know that you'll be working in this role (as a community outreach worker). Please put only one ZIP code PER box. If you don't know the answer to this yet, type "NA" in the first box.

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* 11. Have you been fully vaccinated against COVID-19 (check one)?

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* 12. If you have had one or more shots of the COVID-19 vaccine, please list the vaccine that you received.

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* 13. How old are you?

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* 14. Please check ALL of the following that you identify as:

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* 15. Please check ALL of the following that you identify as:

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* 16. RACE: Please check ALL of the following that you identify as:

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* 17. ETHNICITY: Please check ALL of the following that you identify as:

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* 18. Do you identify as Hispanic or Latino/Latina/Latinx (check one)?

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* 19. Do you speak more than one language fluently?

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* 20. What is your preferred language(s)? 

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* 21. What is your marital status (check one)?

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* 22. What is highest level of school/education that you have successfully completed (check one)?

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* 23. Now we are going to switch gears a bit, and just talk about your job as a community health worker or other type of outreach worker. How many hours do you work in a usual/typical 7-day week - specifically in this job (as a community health worker or other type of outreach worker)? If the hours you work can vary week to week, then enter an average number of weekly hours.

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* 24. In addition to this job (as a community health worker or other type of outreach worker), do you have any other jobs?

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* 25. Do you get paid by the hour for this job as a community outreach worker?

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* 26. Do you get paid by an annual salary for this job as a community outreach worker? If you get paid by the hour instead of with a salary, select "No."

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* 27. What is your annual total household income - including all sources of income for yourself AND for any spouse or long-term partner in the home? Please leave the dollar sign ($) and commas (,) out of your answer and just enter the number (for example enter 1000 for $1,000).

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* 28. Before taking this job, did you have any past experience with community outreach work - including work in community-based outreach and education, public health, or work in a related field?

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* 29. For THIS job as a community health worker or other type of outreach worker, do you plan to use any information/resources/tools provided by the Federal Government (CDC, HHS, HRSA, NIH, etc.) or other government- supported COVID-19 vaccine outreach programs?

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* 30. For THIS job as a community health worker or other type of outreach worker, please select ALL of the following activities/resources that you plan to use as part of your regular job duties (select all that apply):

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* 31. If you plan to follow-up one or more additional times with an unvaccinated community member, after having previously interacted with them, please select ALL of the following methods you plan to use to do this:

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* 32. If you plan to directly assist community members with identifying their nearest vaccine location site(s), please select ALL of the following methods you plan to use to do this:

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* 33. If you plan to directly assist community members with obtaining transportation to a vaccine location site(s), please select ALL of the following methods you plan to use to do this:

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* 34. Please feel free to share any questions, comments, and/or thoughts about the CHW Workforce Collaborative initiative. Your feedback will help ensure that AAPCHO provides appropriate training and/or technical assistance to ensure your success as a community health worker or other type of outreach worker.

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* 35. Thank you / Mahalo / Fa'afetai lava/ Malo aupito for completing this form for AAPCHO and our funder (HRSA). How easy was this form to complete? Select "0" for very hard and "100" for very easy.

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i We adjusted the number you entered based on the slider’s scale.
Thank you for completing this survey.

Please click SUBMIT to submit your data to AAPCHO.

Contact Nashia Choudhury at nchoudhury@aapcho.org if you have any questions and/or issues.

Thank you / Mahalo / Fa'afetai lava/ Malo aupito!
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