CHW Certificate Scholarship Application: Fall 2024 – Minnesota Community Health Worker Alliance

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Please complete the application below to apply to the Minnesota CHW Alliance for Community Health Worker Training Program Scholarship funded by HRSA.

NOTE: This is NOT an application to one of the CHW Certificate Programs.

If you are not a current student and have not yet applied to one of the schools, please email Scholarship@mnchwalliance.org the to get connected to a school. You must be accepted into a college and its CHW Certificate program to be eligible for this scholarship.

CHW Certificate Scholarship Application Fall 2024

Step 1 of 3

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Name(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

County or Tribal Nation of Residence(Required)

Phone(Required)

Email(Required)

Secondary Email

Do you have a high school diploma or GED?(Required)

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)

Please list your current degrees/ licensures/certifications

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)

What kind of support or information would be helpful to you as you prepare for an online learning environment?

What year were you born?(Required)

Please 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)

Are you currently employed?(Required)

What is your current job title?(Required)

Who is your employer?(Required)

Employer Type(Required)

Select 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 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

What is your work address?(Required)

Street Address Address Line 2 City State ZIP Code

County or Tribal Nation of Workplace(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

May the Minnesota Community Health Worker Alliance contact your employer?(Required)

Employer 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)

Do you plan to work as a CHW in Minnesota after receiving your certifcate?(Required)

How 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 Questions

Please 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.

Would you like to upload your responses as a document?(Required)

Yes

Upload Responses

Download this form to complete your answers. Upload it here when ready.

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Max. file size: 50 MB.

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 agree

Consent(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 agree

This field is for validation purposes and should be left unchanged.

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CHW Certificate Scholarship Application Fall 2024

Scholarship Application Questions

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