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Great Plains Area Registration
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First Name
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Work Email
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Address
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Address 2
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Zip
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Title/Work Role
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Credentials/Certifications
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Tribal Organization
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Supervisor Name
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Supervisor Email
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Number of Years as CHR/CHW
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As a CHR, what health topic areas do you support?
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Chronic Disease (Cancer, CVD, DM, HTN, etc.)
Communicable Diseases (STI, HIV, COVID, Hep-C, HPBV, etc.)
Behavioral Health (Substance Use, Suicide Prevention, etc.)
MCH
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Education Level
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High School Diploma
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Type of certifications
Peer Support Certification
Patient Navigator Certification
Health Navigator Certification
Health Coach Certification
Caregiver Certification
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