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Full Name(Required)

Full Name

Email(Required)

Are you:(Required)

A Current CHW

An Ally/Partner

Personal Phone Number (with area code):(Required)

Work Phone Number (with area code):(Required)

Organization you are associated with or work for:(Required)

Number of years as a CHW(Required)

Have you received a certificate of completion by a recognized Delaware CHW training program?(Required)

Yes

No

From what program did you receive your training certificate of completion?

Institute of Public Health Innovation

DelTech

Other

Name of Other Training Program

What county or geographic area do you work in? (Check all that apply)(Required)

New Castle

Kent

Sussex

Statewide

Do you supervise CHWs?

Yes

No

What Priority Group (committee) would you like to join?(Required)

Advocacy

Resource

Training

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