Community Health Work Sustainability Survey
You are receiving this confidential survey because you work as a Community Health Worker (CHW) within a RI organization. This survey was developed as part of a larger collaboration between the RI Department of Health and RI College to document and describe the presence of CHWs across healthcare and other community based organizations in RI. This survey focuses entirely on the sustainability of CHWs.

By completing and submitting this survey, you are agreeing to participate in the CHW assessment that is being initiated by the RI Department of Health and RI College. Your responses will be aggregated with those from other organizations and no individual names will be used. In addition, no organizational names will be used; instead references to fields of practice will be used to represent RI's different industries where CHWs work. The survey includes five sections and will take approximately 15 minutes to complete.

Your participation in this survey is voluntary and can be withdrawn at any time. Completion of this survey indicates your consent. Please submit your survey on or before December 4, 2020.

If you have questions, please contact Tonya Glantz, the Project Investigator, at or by phone at 401-456-4626 or David Zuleta at and Sarah Lawrence at

Thank you for your partnership in this important work.
Email address *
Date completing the evaluation
What is your Name?
What is your Email?
What is your race (check all that apply)?
What is your ethnicity (check all that apply)?
To which gender identity do you most identify?
What is your age?
What is your highest level of education?
What organization do you work for?
What is your job title?
How long have you been employed as a CHW?
In addition to being a CHW, are you also certified as a Peer Recovery Specialist (PRS)?
Would you be interested in a dual certification in Community Health Work (CHW) and Peer Recovery Specialist (PRS)?
We would like to learn more about the experiences of CHW Supervisors too and hope you will share the name(s) and email(s) of your supervisor(s) so that we can send them their own survey, Please use the space below to share your supervisor's name and email information. Thank you!
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy