Screening Questions for Community Health Worker Program Applicants
This form is to serve as a mode of contact information collection and the initial application for anyone looking to participate in Community Health Worker Core Competency Training. Section one is the contact/demographic information section and section two is the screening question sections. 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: https://communityhealthalignment.org/training-faq/
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 *
First and Last name of person invoice for payment should be sent to *
Email of person invoice for payment should be sent to *
For any questions regarding logistics of payment please contact Evangeline Cornelius at ecorneli@mailbox.sc.edu
Bill to: (name of organization) *
Bill to: (address of organization) *
Phone number of person invoice for payment should be sent to *
Start date of Core Competency Training you would like to participate in *
MM
/
DD
/
YYYY
End date of Core Competency Training you would like to participate in *
MM
/
DD
/
YYYY
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