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CHW Certificate Scholarship Application: Spring 2024
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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)
1
2
3
4
5
Did not use online learning system
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)
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
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 Veteran
National Guard
Reservist
Veteran- Prior Service
Veteran- Retired
Are you currently employed?
(Required)
Yes
No
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
No
May the Minnesota Community Health Worker Alliance contact your employer?
(Required)
Yes
No
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.
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