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Certified Community Health Worker Work Experience Verification Form DIRECTIONS This form allows for one employer to document work hours as required for the CCH credential. Provide a separate form
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To fill out the community health worker form, follow these steps:
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Gather all necessary information, such as personal details, education, certifications, and work experience.
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Start by providing your full name, address, contact information, and date of birth.
04
Fill in your educational background, including degrees, certifications, and any specialized training.
05
Enter your work experience, listing previous positions held, organizations worked for, dates of employment, and responsibilities.
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Include any relevant skills or qualifications that would make you a suitable candidate for the community health worker role.
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Provide references from professionals who can attest to your abilities and character.
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Submit the completed form either online or through the specified application process.
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Who needs community health worker?

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Community health workers are needed by various individuals and communities, including:
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- Underserved populations in low-income areas that lack access to healthcare services.
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- Ethnically diverse communities where language and cultural barriers hinder proper healthcare seeking.
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- Individuals with chronic illnesses requiring ongoing support, education, and resources.
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- Vulnerable populations, such as the elderly, individuals with disabilities, or those experiencing homelessness.
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- Communities facing public health emergencies or natural disasters, where coordinated health outreach is crucial.
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- Local governmental organizations or non-profit agencies aiming to improve public health outcomes.
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Community health workers play a vital role in promoting health equity, bridging gaps in healthcare access, and empowering individuals and communities to make informed decisions about their well-being.
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A community health worker is a frontline public health worker who is a trusted member of the community they serve, acting as a liaison between health and social services and the community to facilitate access to services.
Individuals who work as community health workers and are required to report their activities or services provided for state or federal programs must file community health worker documentation.
To fill out community health worker documentation, individuals must provide accurate personal information, report on services rendered, and any relevant certifications or training completed.
The purpose of community health workers is to improve community health outcomes by providing education, support, and resources to community members, ultimately bridging gaps in healthcare access.
Information that must be reported includes the worker's personal details, services provided, number of clients served, training received, and any outcomes achieved as a result of their work.
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