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Community Health Worker Needs Assessment

Please complete this survey to help us understand your needs as a community health worker and the needs of your community. Thank you for your time!

If you have any questions about Triage Cancer or this survey, please email us at info@TriageCancer.org.
1.Please provide your email address to join our newsletter and to be entered into a drawing for a $50 Gift Card (4 prizes available). You will be sent an email if you win.
2.First Name
3.Are you a: (check all that apply)
4.Which state are you located in?
5.What is your current education level?
6.What gender do you identify as?
7.Please specify your ethnicity.
8.On average, how many community members do you reach a month?
9.What language do you primarily use to communicate with your community members?
10.Do members of your community ask for help on how to keep working, or take time off, after a medical diagnosis?
11.How comfortable are you answering community members' questions about the Americans with Disabilities Act (ADA)?
12.How comfortable are you answering community members' questions about the Family and Medical Leave Act (FMLA)?
13.Do members of your community express concern about sharing their diagnosis with others?
14.How comfortable are you answering community members' questions about their options to share their diagnosis with others?
15.Do your community members ask for guidance on health insurance options?
16.How comfortable are you answering community members' questions about health insurance options?
17.Do your community members ask for help to pay for medical care?
18.How comfortable are you answering community members' questions about how to pay for medical care?
19. If a community member is worried about finances, what is usually your first suggestion?
20.Do members of your community ask for help paying for preventative services (e.g., immunizations, cancer screenings)?
21.How comfortable are you answering community members' questions about paying for preventative services (e.g., immunizations, cancer screenings)?
22.Do your community members ask for help to replace lost income if they need time off from work for their health (e.g., disability Insurance)?
23.How comfortable are you answering community members' questions about disability insurance?
24.Would you be interested in any of the following opportunities? Check all that apply. (If yes, please make sure to provide your email above.)
25.Is there anything else you think Triage Cancer should know about the issues your community members are facing?
26.What resources do you find most helpful for your work?
27.If you attended a presentation or event with Triage Cancer, please indicate the name of the event. (e.g. LLS Conference, Insurance & Finance Intensive, NASW Conference)
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