Screening Questions for Community Health Worker Program Applicants
This form is to serve as the initial application for anyone looking to participate in Community Health Worker Core Competency Training. Contingent upon the quality of responses given to the questions below, applicants may be granted eligibility to participate in the CHW Core Competency Training. For more information on the training, please follow this link:
Full Name *
Email Address *
Phone Number *
Current Place of Employment (if employed)
Title at Current Place of Employment (if employed)
Brief Description of Current Position
Brief Description of Current Occupation if not formally employed
City where current place of employment is located (or city you currently live in) *
Would you be willing and able to participate in a training if it were outside of the city you currently live in ? *
If so, how far would you be willing to commute *
Why are you a community health worker or why/ why do you aspire to be a Community Health Worker? *
Define the role “Community Health Worker” in your own words. *
Would you consider yourself a leader in your community? Why/why not? *
Would you consider yourself a Community Health Worker? why/why not? *
How many years have you been a leader and/or Community Health Worker? *
Is there a specific aspect of community health that you are especially passionate about? If so, what is it, and why? *
What do you think are the most important qualities or characteristics a community health worker should have? *
What do you think would be/has been the most challenging part of being a community health worker? *
Describe an experience in which you effectively encouraged or motivated someone to change or adopt a new behavior? *
How do you go about building trust between yourself and others in the community? *
What do you feel are pressing health issues in your community and why? How do you think you might be able to help address these issues? *
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