CHW Renewal Application Please enable JavaScript in your browser to complete this form. – Step 1 of 2Date: *Name: *Home Street Address: *City: *State: *Zip Code: *County: *Telephone: *Email Address: *Currently Employed: *YesNoName of Employer: *Employer Address:Employer City:Employer State:Employer Zip Code:Position Title: *County of Employment: *Are you currently Employed as a Community Health Worker: *YesNoAre you billing as a CHW? *YesNoN/AIf not, what title are you billing under?Have you been promoted or received a raise because you received the CHW certification? *YesNoN/AIf you were unemployed, have you been able to get a job because of the CHW Certification? *YesNoN/ADo you have lived experience with mental illness or substance abuse? PersonalFamily memberFriendNoneNextContinuing Education (CEU) RecordContinuing Education Units (or CEUs) are critical to maintaining professional knowledge in a career as a Community Health Worker. CEUs include time spent learning about mental health, substance use, ethics, and other related topics. CEUs DO NOT include time spent in an employment and/or volunteer position. CEUs are measured in hours (1 hour of learning = 1 hour of CEU). CHW’s are required to complete 14 CEUs each year to maintain their certification.Continuing Education (CEU) #1Training Date: *Provider/Agency: *Instructor/Presenter: *Training Title: *Training Topics: *Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: *Continuing Education (CEU) #2Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #3Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #4Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #5Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #6Training Date: Provider/Agency: Instructor/Presenter:Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #7Training Date: Provider/Agency: Instructor/Presenter:Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #8 Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #9 Training Date: Provider/Agency: Instructor/Presenter:Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #10 Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: Continuing Education (CEU) #11Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #12 Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #13 Training Date: Provider/Agency: Instructor/Presenter: Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours:Continuing Education (CEU) #14 Training Date: Provider/Agency: Instructor/Presenter:Training Title: Training Topics: Mental HealthSubstance UseEthicsCultural CompetenceEnvironmental HealthChronic DiseasesFood/NutritionOtherCEU Hours: SignatureClear SignatureSubmit
