Community Health Worker Training Program: Eligibility Survey

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Thank you for your interest in our CHW Training program. Applications for our next cohort of CHW trainees will open in March of 2024 and run through July. If you would like to be considered for the CHW certification program, complete the following application survey so that we can determine your eligibility for future courses.

Please note, our current training program is intended for underserved Immigrant, Refugee, and Native American communities. If you identify with one or more of these communities, we encourage you to apply.

Visit our CHWAP Website for more information, or email J.W. Wiebe-Anderson, Project Manager, jwiebeanderson@ucsd.edu.

Email *

First Name *

Last Name *

Personal Email Address *

Mobile/Cell Phone Number *

Home Address:

Street Number, Street Name, City, State, Zip Code

Please Re-Enter Your Zip Code *

Date of Birth (month / day / year) *

YYYY

Gender *

Female

Male

Non-Binary/Non-Conforming

Prefer Not To Say

Do you identify as part of a Native American/Indigenous culture, or are you a member of a federally recognized Tribe? *

Yes

How long have you lived in the United States? *

United States Residential Status *

U.S. Citizen

Permanent Residential Visa (Green Card)

Other

What is your home country/country of origin? *

Please list any language skills you have (other than English). *

Education Level Completed *

Some High School / less than 12th grade

Graduated High School or Earned GED (General Education Development)

Some Community College

Graduated Community College / Earned Technical Degree

Some College (4-year University)

Graduated University with a Bachelor's Degree

Graduated University with an Advanced Degree (Master's or Doctorate)

Have you ever served on active duty in the United States Armed Forces, Reserves, or National Guard? *

Yes

How did you hear about this Community Health Worker Training Program? *

Have you received Community Health Worker training or education in the past 3 years? *

Yes

Additional Comments:

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