CDC Work@Health Train-the-Trainer Application Form

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

CDC Work@Health^TM Train-the-Trainer Application Form

Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Respondents/Sources	Method	Content	Timing	Respondents	Time per Respondent
Individuals who are interested in the Work@Health™ Train-the-Trainer model	Work@Health™ Train-the-Trainer Application Form (conducted online by PHMC)	Contact information Assess worksite health knowledge Training experience	Prior to training	60	0.5 hrs

This online form will be available in December 2013 for interested individuals to share their contact information and apply to participate in the Train-the-Trainer model of Work@Health^TM.

Introduction

Informed Consent

We’d like to give you some more information to help you decide whether or not you would like to participate.

• This project is funded by the Centers for Disease Control and Prevention (CDC). Many parts of this project are being managed by the ASHLIN Management Group (ASHLIN). ASHLIN is a private sector consulting firm with a focus in the area of health and human services and is based in Greenbelt, MD. They are helping CDC implement the Work@Health^TM Program. Public Health Management Corporation (PHMC), a non-profit, public health institute located in Philadelphia, PA and part of the ASHLIN Team, designed this form.

• You are being asked to share your contact information so that we can communicate with you about the Work@Health^TM Program.

• Your participation is voluntary, and you may skip any questions you do not want to answer. You may also choose to stop filling out the form at any time.

• This form is designed to take approximately 30 minutes to complete.

• All responses you provide will be maintained in a secure manner. We will not disclose your responses or anything about you unless we are compelled by law. Your responses will be combined with other information we receive and reported in aggregate as feedback from the group. In our project reports, your name will not be linked to the information or comments you provide.

• There are no risks or benefits to you personally for completing this form.

• CDC is authorized to collect information for this project under the Public Health Services Act.

• If you have any questions, you can contact Kristin Minot. Her phone number is 215-985-2519 and her email is Kristin@phmc.org.

The information that we are asking you to provide below will help us to communicate with you about the Work@Health^TM Train-the-Trainer Curriculum. It will also help us to select individuals for the training who have the knowledge and experience to benefit from the Work@Health^TM Train-the-Trainer Curriculum and go on to train and support employers who want to implement or expand a worksite health program.

Contact Information

1. First Name _____________________________________________

2. Last Name _____________________________________________

3. Title __________________________________________________

4. Company/Place of Business _______________________________

5. Street Address _________________________________________

6. City _________________________________________________

7. State _________________________________________________

8. Zip code ______________________________________________

9. Phone number _________________________________________

10. Email address __________________________________________

11. Company website _______________________________________

12. How did you learn about the Work@Health^TM Train-the-Trainer opportunity?

    1. State or local Health Department

    2. Employer membership organization

    3. Community-based health organization

    4. Private/non-profit organization

    5. Colleague

    6. CDC

    7. ASHLIN Management Group

    8. Professional conference

    9. Work@Health™ or CDC website

    10. Participated in a Work@Health™ training

    11. Other _____________________________________________

13. If you checked a through d in question 12 above, please specify the name of the organization or agency _______________________________________________

14. Have you ever implemented a worksite health program in a business, agency, or organization?

1. Yes

2. No

If yes, did you hold a leadership role (i.e., C-suite executive, manager, program director, wellness coordinator) for at least one year at the organization where you implemented a worksite health program?

1. Yes

2. No

15. Please provide a brief description of your experience instructing, coaching, or facilitating employers/ employees in worksite health knowledge and skills including the amount of time (months/years) that you have spent doing this work.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Have you previously completed the Work@Health^TM Core Curriculum training?

    1. Yes

    2. No (skip to Q. 18)

    3. Not sure (skip to Q. 18)

17. If yes, which Work@Health^TM Core Curriculum training model did you participate in? (Check all that apply)

    1. Online

    2. Hands-on

    3. Blended

    4. Not sure

18. Please describe other formal worksite health promotion and protection training you have received over the past 5 years. Who provided the training to you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

19. Please list other professional certifications or credentials you possess in public health, health promotion, occupational health or related fields. (Check all that apply)

a) Registered Dietician

b) Occupational Health Nurse

c) Physician

d) Certified Fitness Instructor/Trainer

e) Certified Tobacco Cessation Counselor

f) Diabetes Educator

g) Certified Health Education Specialist

h) Certified Wellness Practitioner

i) Certified Wellness Program Manager

j) Other (please specify)_______________________________________________

20. Are you committed to fully participate in the Work@Health^TM Train-the-Trainer training and technical assistance?

a) Yes b) No c) Not sure

21. Are you willing to fully participate in Work@Health^TM Train-the-Trainer data collection activities?

a) Yes b) No c) Not sure

22. Are you committed to training at least 5 employers in the Work@Health^TM Core Curriculum after your own training?

a) Yes b) No c) Not sure

23. On a scale of (1) very uncomfortable to (10) very comfortable, how comfortable are you with leading an in-person, hands-on training program? _______________

24. Please supply the contact information for a referral from one of the following types of organizations: State or local Health Department, employer membership organization, community-based health organization, private/non-profit organization.

• Name ___________________________________

• Phone Number ___________________________

• Email ___________________________________

25. Please upload/attachment a letter of support from your referral contact for your training application.

Letter of support attached?

 Yes  No