Form 0917-0036 HCW Application

WEB CONTENT (using Survey Monkey)

FORMAL APPLICATION FOR SUBMISSION

1. Full Name (Open Text Field)

2. Mobile Phone (Open Text Field)

3. Work Address (Open Text Field)

4. What is your current Job Title

   1. Health Educator

   2. CHR/CHW

   3. Diabetes Prevention Educator

   4. Dietitian or Nutritionist

   5. Behavioral Health Counselor

   6. Nurse Educator

   7. Fitness Specialist

   8. Healthcare Provider

   9. Other ___________________

5. What is your place of employment (Open Text Field)

6. What is the name and title of your Immediate Supervisor (Open Text Field)

7. What is your highest education level (select one)

   1. High School Diploma or GED

   2. Professional Certification

   3. Associates Degree

   4. Bachelor’s Degree

   5. Master’s Degree

   6. PhD or MD

   7. Some college but not completed

8. Which one best describes your experiences with Health and Wellness Coaching?

   1. I am a certified Health and Wellness Coach

   2. I am interested in becoming a Health and Wellness Coach

   3. I have worked with a Health and Wellness Coach in the past

   4. I am not familiar with Health and Wellness Coaching and would like to learn more

9. What is your weekly availability to participate in the training program?

   1. Limited availability

   2. <2 hours/week

   3. 2-4 hours/week

   4. 4-10 hours/week

   5. Open availability

10. Indicate (Yes or No) if you are able to meet the listed criteria below after each statement:

• I am available to commit to 6 months to complete all required course work (Yes or No)

• I am able to provide evidence of employment (Yes or No)

• I am able to dedicate 2-4 hours per week to learn course content over 6 months (Yes or No)

• I am able to attend all 26 weekly, virtual web-based learning sessions (once per week at 2 hours per session) (Yes or No)

• I am able to complete all mock coaching and mentor sessions for Practical Coaching Skills Assessment (Yes or No)

• I am able to complete all assignments for each module and two (2) comprehensive exams (Yes or No)

11. If you are a board-certified healthcare provider or clinical educator, would you consider an accelerated course over 3 months? (Yes or No)

(Note: Accelerated courses meet twice per week and require a higher time commitment)