CHW Certificate Scholarship Application <- Return to Scholarship Overview Page CHW Certificate Scholarship Application Summer 2025 Name(Required) First Last Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County or Tribal Nation of Residence(Required)Not a MN ResidentBois Forte Band of ChippewaFond du Lac Band of Lake Superior ChippewaGrand Portage Band of Lake Superior ChippewaLeech Lake Band of OjibweLower Sioux Indian CommunityMille Lacs and of OjibwePrairie Island Indian CommunityRed Lake NationShakopee Mdewakanton Sioux CommunityUpper Sioux CommunityWhite Earth NationAitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac Qui ParleLakeLake Of The WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSaint LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow MedicinePhone(Required)Email(Required) Secondary EmailDo you have a high school diploma or GED?(Required) Yes No Unsure Are you a citizen of the United States or are you a foreign national, having in your possession a visa permitting permanent residence in the United States?(Required) Yes No Unsure Please list all of your current degrees/ licensures/certificationsDo you have training as a Community Health Worker?(Required) Yes No Unsure Please list/describe any Community Health Worker Training you have completed:The CHW Certificate courses are taught via an online portal, on a scale of 1-5, how comfortable are you using internet-based learning systems and other similar technology?(Required)12345What kind of support or information would be helpful to you as you prepare for an online learning environment?What year were you born?(Required)1950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013Please select the cultural or language group that fits you best:(Required) American Indian African American Afghan Asian Indian Burmese Cambodian Chinese Colombian Cuban Dominican Ecuadorian Ethiopian Filipino Ghanaian Guatemalan Haitian Hmong Japanese Kenyan Korean Lao (non-Hmong) Lebanese Liberian Mexican Native Hawaiian Nigerian Nicaraguan Pakistani Puerto Rican Salvadoran Somali Samoan Thai Ukrainian Venezuelan Vietnamese Other What is your race?(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White What is your ethnicity?(Required) Hispanic or Latino Not Hispanic or Latino What is your gender?(Required) Man Woman Non-binary Transgender Please select all languages that you speak/ understand fluently(Required) Amharic Arabic Cantonese Creole Dakota or Lakota Dari English French German Hindi Hmong Ibo K’iche’ Karen Korean Kru Laotian Mam Mandarin Mon-Khmer, Cambodian Nuar Ojibwe or Anishinaabemowin Oromo Pashto Russian Sidamo Somali Spanish Swahili Tagalog Tai-Kadai Telugu Twi Vietnamese Yoruba Other (please list in language/cultural groups above) Please select the languages that you read fluently(Required) Amharic Arabic Cantonese Creole Dakota or Lakota Dari English French German Hindi Hmong Ibo K’iche’ Karen Korean Kru Laotian Mam Mandarin Mon-Khmer, Cambodian Nuar Ojibwe or Anishinaabemowin Oromo Pashto Russian Sidamo Somali Spanish Swahili Tagalog Tai-Kadai Telugu Twi Vietnamese Yoruba Other (please list in language/cultural groups above) Veteran Status(Required)Not a VeteranNational GuardReservistVeteran- Prior ServiceVeteran- RetiredAre you currently, or have you ever been employed as a Community Health Worker?Yes previouslyYes currentlyYes previously and currentlyNoUnsurePlease describe previous work experience as a Community Health Worker:(Required)Are you currently employed?(Required)YesNoWhat is your current job title?(Required)Who is your employer?(Required)What is your work address?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County or Tribal Nation of Workplace(Required)Work not in MinnesotaBois Forte Band of ChippewaFond du Lac Band of Lake Superior ChippewaGrand Portage Band of Lake Superior ChippewaLeech Lake Band of OjibweLower Sioux Indian CommunityMille Lacs and of OjibwePrairie Island Indian CommunityRed Lake NationShakopee Mdewakanton Sioux CommunityUpper Sioux CommunityWhite Earth NationAitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac Qui ParleLakeLake Of The WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSaint LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow MedicineEmployer Type(Required)UnsureAcademic InstitutionAcademic Medical CenterArea Health Education CenterCertified Community Behavioral Health Center (CCBHC)Community Behavioral Health/Mental Health CenterCommunity Health Center (CHC)Critical Access HospitalFederal GovernmentFQHC or Look-AlikeHealth Department (local/state/tribal)Hospital (non-academic)Indian Health Service (IHS)/Tribal/Urban Indian Health CenterNursing HomeOther Clinical Health SettingOther Community-Based OrganizationOther Long-term Care FacilityOther Specialty ClinicPrivate IndustryPrivate PracticeResidential Living Facility (including independent and assisted living)Rural Health ClinicSchool-based ClinicState or Local GovernmentUS Armed ForcesVeterans Affairs Healthcare (e.g. VA hospital or clinic)Pursuing Additional Education or TrainingN/ASelect Type(s) of Vulnerable Populations Served at Employment Setting:(Required) Children or Adolescents Chronically ill College students Financially underserved Geographically underserved Health Insurance Marketplace eligible Individuals Individuals experiencing homelessness Individuals with HIV/AIDS Individuals with mental illness or substance use disorders Lesbian/Gay/Bisexual/Transgender Low income persons/families Medically underserved Migrant workers Military and/or military families Older adults People with disabilities Pregnant women and infants Refugee Adults Socio-culturally underserved Transitional Age Youth (16-25 years) Tribal Population Underrepresented minorities Undocumented Immigrants Unemployed Uninsured/Underinsured persons/families Veterans Victims of interpersonal violence abuse or trauma None of the above N/A Select your primary role at employment setting: (select one)(Required) Not employed as a Community Health Worker Address social determinants of health Advocacy – individual and community Assessment – individual and community Capacity building – individual and community Case management Collect data and relay information to stakeholders to inform programs and policies Conduct outreach Create connections between vulnerable populations and healthcare providers Determine eligibility and enroll individuals in health insurance plans Educate healthcare providers and stakeholders about community health needs Ensure cultural competence among healthcare providers serving vulnerable populations Help patients navigate healthcare and social service systems Manage care and care transitions for vulnerable populations Participate in research and evaluation Provide coaching and/or informal counseling Provide cultural mediation among individuals / communities / health and social service systems Provide culturally appropriate health education Provide interpretation and translation services Provide referrals Provide some direct services such as first aid and blood pressure screening Reduce social isolation among patients N/A Select other roles at employment setting: (select all that apply)(Required) Not employed as a Community Health Worker Address social determinants of health Advocacy – individual and community Assessment – individual and community Capacity building – individual and community Case management Collect data and relay information to stakeholders to inform programs and policies Conduct outreach Create connections between vulnerable populations and healthcare providers Determine eligibility and enroll individuals in health insurance plans Educate healthcare providers and stakeholders about community health needs Ensure cultural competence among healthcare providers serving vulnerable populations Help patients navigate healthcare and social service systems Manage care and care transitions for vulnerable populations Participate in research and evaluation Provide coaching and/or informal counseling Provide cultural mediation among individuals / communities / health and social service systems Provide culturally appropriate health education Provide interpretation and translation services Provide referrals Provide some direct services such as first aid and blood pressure screening Reduce social isolation among patients N/A Please enter the hourly wage that you were paid when you were hired.(Required)How many hours a week do you work in your current job?(Required) 40 hours or more per week 30-40 hours per week Less than 30 hours per week Currently not working Other Do you need to get the CHW Certificate to keep your current job?(Required) Yes No May the Minnesota Community Health Worker Alliance contact your employer?(Required)YesNoEmployer contact: please provide name, title and email or phone number(Required)What is your current household income per month?(Required)What is your current family size?(Required)What school do you plan to attend for your Certification?(Required)UnsureMinnesota West Community and Technical CollegeNormandale Community CollegeNorthwest Technical CollegeSt. Catherine’s UniversitySt. Mary’s UniversityDo you plan to work as a CHW in Minnesota after receiving your certifcate?(Required)YesNoUnsureHow did you hear about the HRSA CHWTP Scholarship Opportunity?(Required) MN CHW Alliance Newsletter/Communication MN Dept of Health Newsletter/Communication Employer Social Media (Facebook, LinkedIn, Instagram) School offering the CHW Certificate Program (e.g. Northwest Tech, Normandale, MN West, etc.) Local Newspaper or Media Community Event or Conference (in person) Webinar or Training (online) Other Other:Scholarship Application QuestionsPlease answer each question below in 250 words per question (1250 characters). You may type your answers into the boxes, or select to upload a PDF document. Short answer questions:How would the CHW Certificate and/or this scholarship benefit you and/or your community?(Required)CHWs are frontline public health workers who have a vital role to play in public health emergencies like COVID-19. How do you see yourself and other CHWs supporting communities in public health emergencies?(Required)Please share a hardship or barrier in your past that you were able to overcome or tell us about a hardship or barrier in your life currently that this scholarship would help you overcome.(Required)Is there anything else that you would like us to know about you?(Required)Consent(Required)By checking this box, I give permission to the Minnesota Community Health Worker Alliance to share de-identified information in this form with the Minnestoa Department of Health (MDH) and the Health Resources and Services Administration (HRSA) for the purposes of grant reporting. I agreeConsent(Required)By checking this box, I give permission to the Minnesota Community Health Worker Alliance to share the information in this form with the accredited schools listed above for the purposes of determining eligibility for this scholarship, verifying acceptance in the CHW program at your chosen school and completing the invoicing process to apply your scholarship to your student account at your chosen school. I agreeEmailThis field is for validation purposes and should be left unchanged. Δ
