Virginia CHW Workforce Development Council Membership Form

Thank you for your interest in joining the Virginia Community Health Worker Workforce Development Council. The goal of the Virginia CHW Workforce Development Council is to identify and promote policy and systems level strategies to advance and sustain the Community Health Worker workforce in Virginia. Achieving health equity and reducing racial and other health disparities by expanding the Community Health Worker Workforce in Virginia are central to the work of the Council.
Please complete the following form so that the Council is aware of your experience and how you can advance the Council’s goal as a member.
The Council meets quarterly and has three standing Committees that meet quarterly. Council leadership is nominated from the membership of the Group. The Council requires a majority of CHW member’s participation in any Council endorsed actions and decisions.

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* 1. Name (First, Last):

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* 2. Best phone number to reach you (include area code):

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* 3. Email Address:

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* 4. If Employed, what is the name of your employer?

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* 5. If you volunteer as a CHW, name of volunteer agency:

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* 6. Your employer or volunteer organization locality (city or county):

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* 7. Zip Code of employer or volunteer agency:

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* 8. Gender Identity:

Female

Male

Non-binary/Third Gender

Prefer to Self-Describe

Prefer Not to Say

Cisgender

Agender

Genderqueer

A Gender Not Listed

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* 9. Race Demographic:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer to Self-Describe

Prefer Not to Say

Some Other Race, Ethnicity, or Origin (please describe in comment box below)

Other Race, Ethnicity or Origin (please specify)

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* 10. Please choose the categories that best describes your position (check all that apply):

Community Health Worker (whether certified or non-certified, employed or volunteer)

Community Health Worker Supervisor (You directly (day-to-day) supervise CHWs)

Community Health Worker Employer (You do not directly supervise CHWs)

Government Employee (Local or Commonwealth of Virginia) and Not a CHW or CHW Supervisor

Advocate/CHW Supporter

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* 11. If you are a CHW, CHW Supervisor, or CHW Employer, how many CHWs are employed where you work or volunteer (please enter the number in the box below)?

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* 12. **Please briefly describe your interest in serving on the CHW Workforce Development Council and what you would like to achieve through your involvement as a member of the Council.**

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* 13. The work of the Council is accomplished through three committees. Please check the committee(s) you are interested in serving on.

CHW Curriculum, Training, and Certification Committee

Policy and Communication

Financing, Measurement, and Evaluation

None

I am interested in serving on a committee but am unable to participate at the current time.

I am interested in providing leadership to the following committee (use comment box):

Interest in committee leadership (please specify committee)

Virginia CHW Workforce Development Council Membership Form

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* 1. Name (First, Last):

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* 2. Best phone number to reach you (include area code):

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* 3. Email Address:

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* 4. If Employed, what is the name of your employer?

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* 5. If you volunteer as a CHW, name of volunteer agency:

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* 6. Your employer or volunteer organization locality (city or county):

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* 7. Zip Code of employer or volunteer agency:

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* 8. Gender Identity:

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* 9. Race Demographic:

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* 10. Please choose the categories that best describes your position (check all that apply):

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* 11. If you are a CHW, CHW Supervisor, or CHW Employer, how many CHWs are employed where you work or volunteer (please enter the number in the box below)?

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* 12. **Please briefly describe your interest in serving on the CHW Workforce Development Council and what you would like to achieve through your involvement as a member of the Council.**

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* 13. The work of the Council is accomplished through three committees. Please check the committee(s) you are interested in serving on.

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* 14. By joining the Council, you agree that you can provide at least 2 hours a month in attendance to Council, committee, or called meetings.

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* 15. Please type your name in the field below:

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* 16. Date Form Completed:

Virginia CHW Workforce Development Council Membership Form

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* 1. Name (First, Last):

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* 2. Best phone number to reach you (include area code):

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* 3. Email Address:

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* 4. If Employed, what is the name of your employer?

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* 5. If you volunteer as a CHW, name of volunteer agency:

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* 6. Your employer or volunteer organization locality (city or county):

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* 7. Zip Code of employer or volunteer agency:

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* 8. Gender Identity:

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* 9. Race Demographic:

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* 10. Please choose the categories that best describes your position (check all that apply):

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* 11. If you are a CHW, CHW Supervisor, or CHW Employer, how many CHWs are employed where you work or volunteer (please enter the number in the box below)?

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* 12. Please briefly describe your interest in serving on the CHW Workforce Development Council and what you would like to achieve through your involvement as a member of the Council.

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* 13. The work of the Council is accomplished through three committees. Please check the committee(s) you are interested in serving on.

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* 14. By joining the Council, you agree that you can provide at least 2 hours a month in attendance to Council, committee, or called meetings.

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* 15. Please type your name in the field below:

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* 16. Date Form Completed:

* 12. **Please briefly describe your interest in serving on the CHW Workforce Development Council and what you would like to achieve through your involvement as a member of the Council.**