CHW Success Story Submission Form
Please complete the following form with your Community Health Worker success story.
IMPORTANT! Do NOT share a client’sname and/or confidential/HIPAA-protected information.
Submitter Name
First Name
Last Name
Submitter Organization
Submitter Email
example@example.com
CHW Name
First Name
Last Name
CHW Organization
CHW Email
example@example.com
Client Background
Maintaining the client’s privacy, please describe the client’s background and why they were referred to the CHW program?
What was the problem or challenge the client was facing?
Services Provided
What steps did the CHW take to achieve a positive outcome?
What services and resources helped achieve a positive outcome for the client?
How many visits, or how much time spent, did the CHW have with the client?
How will the CHW continue to help provide care to the client? For example, did they provide a referral to another organization for long-term case management?
Was the CHW able to bill for services provided?
CLIENT SUCCESS:
How did this situation become a success story? How did working with a CHW impact the client’s health?
Who were the key players/health care providers/partner agencies involved?
ADDITIONAL INFORMATION:
Please provide additional information you feel is relevant to the success story.
Would you be willing to share this story at a CHW event?
Yes
No
Submit
Should be Empty: