The Arizona Community Health Workers Association and Arizona Department of Health Services are partnering and supporting CHWs with the CHW Voluntary Certification/Recertification fees

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Please enter your first and last name.
*

Please enter your email. *

Enter the name of your organization. *

What is your job title/position?
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Are you a CHW/CHR/Promotor(a)?
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CHW

CHR

Promotor(a)

No, I am not a CHW/CHR/Promotor(a)

If yes, for how long have you been a CHW/CHR/Promotor(a)?
*

1-5 Years

5-10 Years

10+ Years

No, I am not a CHW/CHR/Promotor(a)

Please enter your work zip code.
*

Which of the following best describes the type of your organization?
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Community Based Organization

Health Clinic/Hospital

Community Health Center

Government Agency

Other:

In which Arizona county (counties) do you work? (Select all that apply)
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Santa Cruz County

Cochise County

Pima County

Pinal County

Maricopa County

Yuma County

Coconino County

Mohave County

Yavapai County

Gila County

Navajo County

Apache County

Greenlee County

La Paz County

Graham County

Required

Please enter you supervisor contact information (Name, email, phone number, etc). *

Please select your ethnicity.
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White

Hispanic or Latino

Black or African American

Native American or Alaskan Native

Asian

Other:

Required

I am applying for... *

CHW Voluntary Certification for the first time.

CHW Voluntary Recertification.

When do you plan to apply for ADHS CHW Voluntary Certification/Recertification?
*

Which of the 4 Pathways for Certification will you choose? *

Pathway #1: 960 hours of paid or volunteer experience providing CHR or CHW services in the core competencies, during the previous three-year time-period.

Pathway #2: Completion of a CHW certificate program, including core competencies, provided by an accredited college, and 480 hours of paid or volunteer CHR or CHW experience completed during the previous three years.

Pathway #3: Completion of a CHW training program provided by an organization or certified CHW trainer, including core competencies and 480 hours of paid or volunteer CHR or CHW experience completed during the previous three years.

Pathway #4: Completion of a CHR National Training Program (provided by IHS). This is basic training certification and 480 hours of paid or volunteer CHR or CHW experience completed during the previous three years OR Advanced training certification and 380 hours of paid or volunteer CHR or CHW experience completed during the previous three years

I am applying for recertification.

Has your organization received a scholarship for CHW certification or recertification from AzCHOW in the past year? *

Yes

I'm not sure

If yes, approximately how many scholarships has your organization received in the past year? (Optional)

Thank you for submitting your application!

For any questions, comments or concerns please contact Richard Redondo at richard@azchow.org or Francisco Oros at francisco@azchow.org.

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