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First Name
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Last Name
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Ethnicity
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White
Black or African American
Hispanic or Latino Central American
Hispanic or Latino Mexican
Hispanic or Latino South American
Hispanic of Latino (Other)
Native American or Alaska Native
African (Black)
Asian
Pacific Islander
Two or More Races
Some Other Race
Decline to Answer
Zip Code
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Gender
Female
Male
Trans Female / Trans Woman
Trans Male / Trans Man
Genderqueer, Gender Non-conforming, or Nonbinary Gender
Work Status
Full-time employee
Part-time employee
Not currently employed
Community Health Worker Volunteer
Permission to SHARE INFORMATION about VACHW
Yes
No
Work Localities
Accomack
Albemarle
Alleghany
Alexandria City
Amelia
Amherst
Appomattox
Arlington
Augusta
Bath
Bedford
Bland
Botetourt
Bristol City
Brunswick
Buchanan
Buckingham
Buena Vista City
Campbell
Caroline
Carroll
Charles City
Charlotte
Charlottesville City
Chesapeake City
Chesterfield
Covington City
Craig
Culpeper
Cumberland
Danville City
Dickenson
Dinwiddie
Emporia City
Essex
Fairfax
Fairfax City
Falls Church City
Fauquier
Floyd
Fluvanna
Franklin
Franklin City
Fredericksburg City
Galax City
Giles
Gloucester
Goochland
Grayson
Greene
Greensville
Halifax
Hampton City
Hanover
Harrisonburg City
Henrico
Henry
Highland
Hopewell City
Isle of Wight
James City
King and Queen
King George
King William
Lancaster
Lee
Lexington City
Loudoun
Louisa
Lunenburg
Lynchburg City
Martinsville City
Mathews
Mecklenburg
Middlesex
Montgomery
Nelson
Norfolk City
Northumberland
Norton City
Nottoway
Orange
Page
Patrick
Petersburg City
Pittsylvania
Poquoson City
Portsmouth City
Powhatan
Prince Edward
Prince George
Prince William
Pulaski
Radford City
Rappahannock
Richmond
Richmond City
Roanoke
Roanoke City
Rockbridge
Rockingham
Russell
Salem City
Scott
Shenandoah
Smyth
Southampton
Spotsylvania
Suffolk City
Surry
Sussex
Tazewell
Virginia Beach City
Warren
Waynesboro City
Washington
Westmoreland
Williamsburg City
Winchester City
Wise
Wythe
York
Other Locality (s)
Position Title (Select all that apply)
Community Health Worker
Doula
Outreach Worker
Lay Health Promoter/Promotores de Salud
Peer Support Specialist
Patient or Client Navigator
Community Health Advisor/Promoter
Care Manager (not licensed as a nurse or other licensed professional)
Lifestyle Coach/Advisor
Home Visitor
Other Position (s)
Position Roles (Select all that applies)
Providing care coordination
Providing health promotion and disease prevention education
Making referrals and providing follow-up
Connecting people to services
Helping people meet basic needs
Helping people navigate health and human service systems
Providing individual support and coaching
Advocating for clients and communities
Building health literacy and cross-cultural communication
Other
Language Spoken (select all that applies)
English
Spanish
French
Mandarin Chinese
Swahili
Hindi
Russian
Standard Arabic
Portuguese
Bengali
Other Language (s)
Certification Status
Not Applicable
Community Health Worker – Certified
Community Health Worker - Not Certified
Peer Recovery Specialist - Certified
Membership Associations
Virginia CHW Association (VCHWA)
National CHW Association
Other Association
Not any Association member
If Certified: Certification Number
If Certified: Expiration Date
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