SPSI Program Completion Form – Minnesota Community Health Worker Alliance

The Minnesota Community Health Worker Alliance’s (Alliance) invites you to take this survey to help us evaluate Student Parent Support Initiative. We would like to learn about the resources you accessed through the Alliance and MN West while working on your Community Health Worker (CHW) Certificate program, any challenges you experienced, and feedback about the program.

The Alliance staff, who are CHW certificate holders, will have access to your responses but will remove any identifying information from your survey data before sharing with our external evaluator, Professional Data Analysts. They will be responsible for analyzing data and reporting to our funder, but your names and identity will not be shared with them or in any of our evaluation reports. Rather the data will be aggregated or combined across students to share outcomes of this program. The evaluation will help us understand how well we supported student parents, how the support affected CHW certificate completion rates, and how we can improve our support in the future.

The survey should only take 15-20 minutes. We ask that you answer the questions honestly and to the best of your ability, to help us understand how to best support student parents in the future. Please complete this survey by June 15th 2026.

If you have any questions about the survey or how the data will be used, please contact Rachel Stoll at info@mnchwalliance.org.

SPSI Discharge Survey

First Name

Last Name

Housing Status

What is your housing status today?

I have a steady place to live

I have a place to live today, but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, in a car, abandoned building, etc.)

Prefer not to answer

Food

Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 6 months.

Within the past 6 months, you worried that your food would run out before you got money to buy more.

Often true

Sometimes true

Never true

Prefer not to answer

Within the past 6 months, the food you bought just didn’t last and you didn’t have money to get more.

Often true

Sometimes true

Never true

Prefer not to answer

Transportation

In the past 6 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?

Yes

Prefer not to answer

Utilities

In the past 6 months, has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes

Already shut off

Prefer not to answer

Financial Stability

Childcare

Is getting childcare a barrier for you to be able to work or study?

Yes

Prefer not to answer

Safety

General Health

How would you describe your healthcare coverage/health insurance situation?

I have health insurance that I consider affordable.

I have health insurance, but it is not affordable.

I do not have health insurance

Prefer not to answer

In the past 6 months, have you skipped or delayed any needed care (medical, dental, mental health) due to cost?

Yes

Don’t know/Not Sure

Prefer not to answer

Physical Health

Thinking about your physical health, which includes physical illness and injury. Over the past 30 days, how often was your physical health not good?

Not at all

Several days

More than half the days

Nearly every day

Prefer not to answer

During the past 30 days, did your physical health keep you from doing your usual activities, such as self-care, work, recreation, or things you enjoy?

Yes

Don’t know/Not sure

Prefer not to answer

Mental Wellbeing

Over the past 2 weeks, how often have you had little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Prefer not to answer

Over the past 2 weeks, how often have you been feeling down, depressed or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Prefer not to answer

During the past 30 days, did your mental health keep you from doing your usual activities, such as self-care, work, recreation, or things you enjoy?

Yes

Don’t know/Not sure

Prefer not to answer

Barriers

Resources Accessed

Minnesota West offers Student Services to help support individuals while they are in school, did you access (or use) any of the following resources offered through Minnesota West?

Laptop checkout

Internship support

Printing or copying (offer $12.50 to print up to 250 pages free of charge per semester through library)

Mental health & wellness services

Childcare

Food and personal care

I did not use any of these resources

I could not access the resources or had challenges accessing the resources

Other

Helpfulness of program support/resources

How helpful were the resources/supports that The Alliance staff provided you with during the CHW certificate program?

	Very Helpful	Mostly Helpful	Somewhat Helpful	Not at all Helpful	I did not use this resource or support
Community resource navigation (food assistance, housing, utilities, transportation, childcare, etc.)
Healthcare resource navigation (medical, dental, mental health, or insurance)
Employment support (resume, mock interviews, job searching, etc.)
One-on-one meetings with the Alliance staff
Monthly cohort meetings
Tuition/fee support for CHW certificate program
Stipend ($1,000)

Which resources contributed to your ability to complete the CHW certificate program? (Select all that apply)

Community resource navigation (food assistance, housing, utilities, transportation, childcare, etc.)

Healthcare resource navigation (medical, dental, mental health, or insurance)

Employment support (resume, mock interviews, job searching, etc.)

One-on-one meetings with the Alliance staff

Monthly cohort meetings

Tuition/fee support for CHW certificate program

Stipend ($1,000)

None of the resources contributed to my ability to complete the certificate program

How did the Alliance’s support and resources help you complete the CHW certificate program?

Did the Alliance’s support and resources help improve your health or wellbeing while in the CHW certificate program?

Yes

I did not need support or resources to improve my health or wellbeing

I don’t know

How did the Alliance’s support and resources help improve your health or wellbeing while in the CHW certificate program?

Cultural Responsiveness of the Curriculum

“Cultural responsiveness” means that the content and materials of the classes reflect, validate and incorporate diverse cultural backgrounds, prior experience and unique learning styles of all students. Read more about this topic if you are interested: https://guides.library.pdx.edu/c.php?g=527355&p=3623937

	Agree	Somewhat agree	Somewhat disagree	Disagree
The CHW curriculum promotes understanding and appreciation of different cultural backgrounds.
The CHW curriculum encourages students to critically examine and challenge stereotypes and biases.
The CHW curriculum promotes the inclusion of multiple perspectives and voices in discussions and assignments.

Satisfaction

How satisfied are you with:

Improvements:

How could the Alliance improve the support and resources they provide student parents?

How could MN West improve the support they provide student parents?

How could the CHW certificate program and curriculum be improved?

What else would you like to share about your experience with the Alliance or the CHW Certificate program?

By checking this box, I give permission to the Minnesota Community Health Worker Alliance to share de-identified information in this form with the Minnesota Department of Higher Education for the purposes of grant reporting, and to an evaluator at Professional Data Analysts for the purpose of program evaluation.

	Yes	No	Don’t know/Not Sure	Not Applicable	Prefer not to answer
At home
At work
At school
In our community
With family

	Yes	No	Don’t know/Not Sure	Not Applicable	Prefer not to answer
At home
At school
In our community
With family

	Very satisfied	Mostly satisfied	Somewhat satisfied	Not at all satisfied
Support you received from the Alliance
Support you received from the school, MN West
CHW Certificate program

Cart

Housing Status

Food

Transportation

Utilities

Financial Stability

Childcare

Safety

General Health

Physical Health

Mental Wellbeing

Barriers

Resources Accessed

Helpfulness of program support/resources

Cultural Responsiveness of the Curriculum

Satisfaction

Improvements: