Community Health Worker Program Information

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1 Community Health Worker Program Information Thank you for your interest in becoming a Certified Community Health Worker (CHW). Community Health Workers are frontline public health workers who are trusted members and have a close understanding of the community they serve. CHWs help to build client and community health knowledge and self-sufficiency through outreach, community education, social support, and advocacy. The University of Toledo Area Health Education Center (AHEC) Partnership for Community Health Workers was awarded funding to increase the number of Certified CHW s in Northwest Ohio serving the Medicaid population. This partnership between the University of Toledo AHEC program, the Hospital Council of Northwest Ohio s Northwest Ohio Pathways HUB, and CHW Certificate Programs at Mercy College of Ohio and North Central State College is working together to attract, train and retain CHWs interested in serving Ohio s Medicaid eligible population. Below is information for the Mercy College of Ohio and North Central State College Community Health Worker Certificate Training programs. Both CHW programs include classes and supervised clinical practicum training at a professional work site. The tuition stipend application is attached for those interested in applying for a University of Toledo AHEC Partnership for Community Health Workers Tuition Stipend. A limited number of tuition stipends are available for students in the CHW Certificate program at either Mercy College of Ohio or North Central State College. To apply for the tuition stipend, applicants need to apply to one of these two CHW certificate programs. If selected for the tuition stipend, recipients must agree to meet the following requirements: Complete a satisfactory background check and fingerprinting prior to accepting the tuition stipend. Successfully complete the CHW training program, including practicum hours. Obtain their CHW Certification from the Ohio Board of Nursing. Commit to serving the Medicaid population for at least 12 months after obtaining CHW Certification. Mercy College of Ohio North Central State College (classes held on The University of Toledo Health Science campus) CHW Certificate Training Program Dates Total Credit Hours Clinical Practice Practicum at approved professional work site Value of University of Toledo AHEC Partnership for Community Health Workers Tuition Stipend For additional CHW Certificate Training Program information For additional Tuition Stipend information August 17, May 8, 2016 Fall 2015: September 14, December 4, 2015 (10 full days of classes September 14-17, October 5-8 and December 3-4, online assignments and a clinical practicum) or Winter 2016: January - April, 2016 (Dates are being finalized) (10 full days of classes, online assignments and a clinical practicum) 16.5 hours (8 courses, including practicum) Minimum of 150 hours (15 weeks - minimum of 10 hours per week) (January - May 2016) $3,000 $2,400 Candace Tavormina, RN, MSN, CNE Mercy College of Ohio candace.tavormina@mercycollege.edu Chris Demko Hospital Council of Northwest Ohio cdemko@hcno.org 9 hours (3 courses, including practicum) Minimum of 130 hours (9 weeks - minimum of 14 hours per week) (Fall 2015: September - November 2015) (Winter 2016: January - April 2016) Anne Seifert, MEd North Central State College aseifert@ncstatecollege.edu Chris Demko Hospital Council of Northwest Ohio cdemko@hcno.org

2 To apply for the Mercy College of Ohio Community Health Worker Certificate Training program, please complete your CHW program application online at mercycollege.edu/chw by clicking on the APPLY NOW button.

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5 University of Toledo AHEC Partnership for Community Health Workers Tuition Stipend Application Thank you for your interest in the University of Toledo Area Health Education Center (AHEC) Partnership for Community Health Workers (CHW) Tuition Stipend. Funding for these tuition stipends is provided from the University of Toledo MEDTAPP Healthcare Access Initiative through a grant from the Ohio Colleges of Medicine Government Resource Center. Please complete this application in full and submit to the Hospital Council of Northwest Ohio no later than: Monday, August 10, to apply for a Mercy College of Ohio CHW tuition stipend, or Monday, August 31, to apply for a North Central State College CHW tuition stipend. By Mail: By By Fax: Community Health Workers Tuition Stipend ATTN: Chris Demko Hospital Council of Northwest Ohio 3231 Central Park West Drive, Suite 200 Toledo, OH cdemko@hcno.org ATTN: Community Health Workers Tuition Stipend Fax Number: Indicate which CHW program you have applied to: Mercy College of Ohio - August 17, May 8, 2016 North Central State College (classes held on The University of Toledo Health Science campus) o Fall Session - September 14 - December 4, 2015, or o Winter Session - January - April, 2016 (Dates are still being finalized) How did you learn about this CHW Tuition Stipend? 2. Applicant Contact Information: LAST NAME FIRST NAME MIDDLE INITIAL STREET ADDRESS STREET ADDRESS (SECOND LINE) CITY STATE ZIP CODE PHONE ADDRESS I have been a resident of Ohio for the previous 3. Date of Birth: (MM/DD/YY) Female 4. What is your race? (CHECK ALL THAT APPLY) American Indian/Alaska Native Asian Black or African-American Native Hawaiian/other Pacific Islander White 5. Are you Hispanic or Latino? Yes No

6 6. Indicate your annual household income from all sources: Less than $10,000 $10,000 to $19,999 $20,000 to $34,999 $35,000 to $49,999 $50,000+ Number of people living in household: 7. Highest level of education completed: GED (Indicate date of completion): High School Diploma (Indicate graduation date): Some college Associate s degree Bachelor s degree More than a 4 year degree 8. Are you currently employed? Yes, Name of Employer: No, skip to question 11 Job Title: 9. Do you currently serve the Medicaid population? Yes, what services do you provide? No 10. The CHW certificate program requires all students to complete a practicum experience (hours vary based on selected program). Practicums must take place at an approved professional work site that serves the Medicaid population to broaden your experience in CHW practice. Is your current employer willing and able to supervise you while completing this practicum requirement? Yes, Name of Supervisor: Job Title: Mailing Address: Address: Phone: No If no, would you be able to complete the practicum at another site in addition to your current job duties? Please explain: 11. Please describe your transportation arrangements: 12. List the names and contact information for your references, limited to three (3) total: Name: Phone Number or Relationship: 13. In 500 words or less, please describe how you plan to better our community after obtaining your CHW certification through this tuition stipend program (use a separate sheet of paper). 14. Please include a current copy of your resume when submitting the completed application.