Community Health Worker Host Site Interest Form

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Please fill out this form if you are interested in hosting community health worker (CHW) interns or apprentices at your organization. Someone from our team will be in touch with you within one week of submitting this form.

Name *

Organization *

Job Title *

Email *

Phone Number *

Preferred Method of Contact *

Phone

Both

Best time to contact: *

Morning

Lunch hour

Afternoon

Evening

Required

My organization is most interested in (select all that apply): *

Hosting CHW interns (approximately 120 hour internship)

Hosting CHW Apprentices (1-year, 2000 hour commitment)

Organization staff participating in the CHW training program as trainees

Unsure, need more information

Required

City or cities in Colorado where organization or opportunity is located: *

If interested in hosting CHW interns or apprentices, type of experience your organization can offer:

On-site

Remote

Hybrid

Date available to start hosting CHWs:

Summer 2023

Fall 2023

Winter 2023/2024

Unsure

Other:

Clear selection

Please briefly describe additional detail about the internship, apprenticeship, or training opportunity your organization is interesting in hosting or participating in for CHW trainees, such as focus of work, populations served, potential duties/responsibilities, number of CHWs able to host, limitations/challenges in supporting the trainee, etc. *

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