CHWTP Scholarship- Student Withdraw Survey Student Withdraw Survey Name(Required) First Last Email(Required) What school did you attend for your Certificate?(Required) Normandale Community College Northwest Technical College Minnesota West Community and Technical College Saint Mary’s University of Minnesota St. Catherine’s University On a scale of 1-5, how comfortable were you using the internet-based learning systems that you had to use for this certificate program (D2L etc.)?(Required)12345Did not use online learning systemWhat kind of support or information would have been helpful to you as attempted to complete your certificate in an online learning environment?(Required)What is the main reason that you were unable to complete the CHW Certificate course?(Required) Financial stressors Program was not was you expected Time commitment Workload Online learning platform (D2L) Personal or family reasons Language barriers Internship expectations Concern about job opportunities for CHWs Problems with the school or faculty Problems with MN CHW Alliance staff Other What kind of support would have made it easier for you to continue in the CHW Certificate program?(Required) School based support Technology support Peer to peer support Mentotorship support More knowledge about the CHW profession Support with internship course component Other If possible, would you want to apply your scholarship dollars to complete the certificate at a later date?(Required) Yes No Unsure Please select the cultural group that fits you best American Indian African American Afghan Asian 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 White or European Other Please select all languages that you speak(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 employed?(Required)YesNoWhat is your current job title?(Required)Who is your employer?(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)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 PhoneThis field is for validation purposes and should be left unchanged. Δ
