1 CHW Application

American Heart Association
National Hypertension Control
Initiative Community Health Worker / Promotor(a) Pilot Program
Enrollment Form
Welcome and thank you for your interest in the Community Health Worker Pilot Program.
Please answer the following questions.
First, we would like to know some more about your background...
1. What is your race? Select one or more.
a. Asian
b. American Indian or Alaska Native
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Other (please specify): __________
g. Don’t know/Not sure
h. Prefer not to answer
2. Are you Hispanic or Latino?
a. Yes
b. No
c. Don’t know/Not sure
d. Prefer not to answer
3. Do you consider yourself to be male or female?
a. Male
b. Female
c. Other (please specify): __________
d. Don’t know/Not sure
e. Prefer not to answer
4. In what city, state or U.S. territory do you reside? City: ____________ State/Territory: ______________
Prefer not to answer
5. What is your age group?
a. 18-29
b. 30-39
c. 40-49
d. 50-59
e. 60-64
f. 65 or older
g. Prefer not to answer
6. What is the highest level of education that you have completed?
a. Less than high school
b. Some high school
c. High school graduate or equivalent
d. Associate degree (such as AA, AS)
e. Some college
f. Bachelor’s degree (such as BA, BS)
g. Graduate degree (such as MBA, MS, MD, PhD)
h. Don’t know/not sure
i. Prefer not to answer

American Heart Association
National Hypertension Control
Initiative Community Health Worker / Promotor(a) Pilot Program
Enrollment Form

Please respond to the following questions about your experience as a Community Health Worker.
7. Are you a Community Health Worker?
a. Yes
b. No
c. Don’t know/not sure
d. Prefer not to answer
8. Are you a certified Community Health Worker in any state?
a. Yes
b. No
c. Don’t know/not sure
d. Prefer not to answer
9. In what state or U.S. territory did you receive your Community Health Worker Certification?
[Dropdown box to select the state]
10. Are you a member of the National Association of Community Health Workers (NACHW)?
a.
b.
c.
d.

Yes
No
Don’t know/Not sure
Prefer not to answer

11. Are you a member of your state Community Health Worker Association?
a. Yes
b. No
c. Don’t know/Not sure
d. Prefer not to answer
12. Are you currently employed or do you volunteer as a Community Health Worker?
a. Employed
b. Volunteer
c. Both
d. No, I am not employed and do not volunteer as a Community Health Worker
e. Don’t know/Not sure
f. Prefer not to answer
13. Did you work at any of the following Community-based Organizations in 2023?
a. Mission YMCA, San Francisco, CA
b. Samuel Merritt University, Oakland, CA
c. Northern California Center for Wellbeing, Santa Rosa, CA
d. Hope Village Revitalization, Detroit, MI
e. One Stop Career Center of Puerto Rico
f. Black Nurses Rock
g. No, I did not work at any of these organizations in 2023
h. Prefer not to answer

American Heart Association
National Hypertension Control
Initiative Community Health Worker / Promotor(a) Pilot Program
Enrollment Form

14. Did you work at any of the following Community Health Centers in 2023?
a. Mission Area Health Associates, San Francisco, CA
b. Northeast Medical Services, San Francisco, CA
c. Lifelong Medical Care, Oakland, CA
d. Santa Rosa Community Health Centers, Santa Rosa, CA
e. The Wellness Plan, Detroit, MI
f. Covenant Community Care, Inc., Detroit, MI
g. Community Health and Social Services Center, Inc., Detroit, MI
h. Detroit Community Health Connection, Detroit, MI
i. Western Wayne Family Health Centers, Detroit, MI
j. Camuy Health Services Inc, Puerto Rico
k. Centro De Salud De Lares Inc, Puerto Rico
l. Centro De Servicios Primarios De Salud Inc, Puerto Rico
m. Corporacion De Salud Asegurada Por Nuestra Organizacion Solidaria, Inc. (S.A.N.O.S.), Puerto
Rico
n. Neomed Center, Inc., Puerto Rico
o. Centro De Salud Familiar Dr. Julio Palmieri Ferri, Inc., Puerto Rico
p. No, I did not work at any of these Community Health Centers in 2023
q. Prefer not to answer
Thank you for your participation in the CHW Community Pilot Program!