Rev. 7-28-2015
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
August 17, 2015 - May 8, 2016 Fall 2015:
September 14, 2015 - 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)
Total Credit Hours 16.5 hours (8 courses, including practicum) 9 hours (3 courses, including practicum)
Clinical Practice Practicum at approved professional work site
Minimum of 150 hours
(15 weeks - minimum of 10 hours per week) (January - May 2016)
Minimum of 130 hours
(9 weeks - minimum of 14 hours per week)
(Fall 2015: September - November 2015) (Winter 2016: January - April 2016)
Value of University of Toledo AHEC Partnership for Community Health Workers Tuition Stipend
$3,000 $2,400
For additional CHW
Certificate Training Program information
Candace Tavormina, RN, MSN, CNE Mercy College of Ohio
419-251-1815
Anne Seifert, MEd
North Central State College 419-571-7832
For additional Tuition Stipend information
Chris Demko
Hospital Council of Northwest Ohio 419-842-0800
Chris Demko
Hospital Council of Northwest Ohio 419-842-0800
To apply for the Mercy College of Ohio Community Health Worker Certificate
Training program, please complete your CHW program application online at
Rev. 7-28-2015
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, 2015 - to apply for a Mercy College of Ohio CHW tuition stipend, or
Monday, August 31, 2015 - to apply for a North Central State College CHW tuition stipend.
By Mail: Community Health Workers Tuition Stipend
ATTN: Chris Demko
Hospital Council of Northwest Ohio 3231 Central Park West Drive, Suite 200 Toledo, OH 43617
By Email: [email protected]
By Fax: ATTN: Community Health Workers Tuition Stipend
Fax Number: 419-842-0999
1.
Indicate which CHW program you have applied to: Mercy College of Ohio - August 17, 2015 - 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 E-MAIL ADDRESS
I have been a resident of Ohio for the previous
3.
Date of Birth: ___________ (MM/DD/YY) Female4.
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
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: ________________________________ Job Title: ____________________
No, skip to question 11
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: _____________________________________________________________________ E-Mail 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 Email: Relationship:
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
13.
In 500 words or less, please describe how you plan to better our community after obtaining your CHWcertification through this tuition stipend program (use a separate sheet of paper).
