CHWTP Scholarship- Student Withdraw Survey

Student Withdraw Survey

Name(Required)

First Last

Email(Required)

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)

What 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)

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

Unsure

Please select the cultural group that fits you best

Please select all languages that you speak(Required)

Veteran Status(Required)

Are you currently employed?(Required)

What 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

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)

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

Name

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