RICB CCHW Application | Revised August 2021
APPLICATION INSTRUCTIONS – READ CAREFULLY
Prior to applying, all requirements must be met and documented.
Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: RICB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: inf[email protected] NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not
indicate it has been received. To confirm receipt of application, email info@ricertboard.org
.
REVIEW & APPROVAL PROCESS
1. Application submitted to RICB. To confirm receipt of application, email RICB at the above email address.
2. Staff reviews application. Allow up to 10 business days for review and processing.
3. Applicant will be emailed if there is any documentation missing or there are questions regarding an
application. Applications with pending problems will be held open for one year from date of receipt
after which they will be closed.
4. A certificate will be mailed to you within 10 business days.
CCHW APPLICATION
Certified Community Health Worker
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ROLE OF THE COMMUNITY HEALTH WORKER
Community Health Workers are frontline public health workers who are trusted members of the community
they serve. This trusting relationship enables them to serve as a liaison/link/intermediary between health/social
services and the community to facilitate access to services and improve the quality and cultural responsiveness
of service delivery.
Community Health Workers build individual and community capacity by increasing health knowledge and self-
sufficiency through a range of activities such as engagement, community education, social support and
advocacy. Community Health Workers hold a unique position within an often rigid health care system in that
they can be flexible and creative in responding to specific individual and community needs.
The unique strength of Community Health Workers is their ability to develop rapport with people and other
community members due to shared culture, community residence, chronic condition, disability, language, and
life experiences. They are also able to enhance the cultural and linguistic appropriateness of care and help to
counteract factors such as social exclusion, poverty, and marginalization.
An important role of the Community Health Worker is to advocate for the socioeconomic, environmental, and
political rights of individuals and their communities. Community Health Workers often link people to needed
health information and services.
Community Health Workers address the social and environmental situations that interfere with an individual or
community achieving optimal health and well-being.
Community Health Worker’s may have various titles as it is used as an umbrella term.
CERTIFIED COMMUNITY HEALTH WORKER REQUIREMENTS
All requirements below must be met to apply. All required documentation must be sent in with an application
except for the official college transcript which is sent to RICB directly prior to application.
DOMAINS
1. Engagement Methods and Strategies
2. Individual and Community Assessment
3. Culturally and Linguistically Appropriate Responsiveness
4. Promote Health and Well-Being
5. Care Coordination and System Navigation
6. Public Health Concepts and Approaches
7. Advocacy and Community Capacity Building
8. Safety and Self-Care
9. Ethical Responsibilities and Professional Skills
EDUCATION/TRAINING
REQUIRED: 70 total hours of relevant education/training specific to the
Community Health Worker domains.
Education is defined as formal, structured instruction in the form of workshops, trainings, seminars, in-services,
college/university credit courses, and online education.
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There is no limit to the amount of online education that may be submitted.
Most three-credit college/university courses count as 45 hours. One training CE/CEU counts as one hour.
Out of state education is acceptable.
All education/training must be documented. College courses are documented with an official college transcript.
Trainings are documented with copies of training certificates.
Training certificates must have the applicant’s name, title of training, date(s) of training, the number of hours
being awarded, and the name of training organization. Training certificates submitted without this required
information on them will not be accepted.
If a training title on a certificate of attendance does not clearly indicate the education content, attach a copy of
the training description.
Training registration forms and/or training sign-in sheets are not acceptable forms of documentation.
Training must be non-repetitive meaning the same training cannot be claimed more than one time even if the
training is taken on different dates from different providers.
Official employer training tracking system/learning management system reports may be acceptable forms of
documentation for education/training provided that the report contains the name of the employee/applicant,
titles of each training, dates of each training, the number of hours of each training, and is signed by the
applicant’s supervisor.
There is no time limit on when the education/training was received.
COMMUNITY HEALTH WORKER EXPERIENCE
REQUIRED: Six (6) months of full-time experience or 1000 hours part-time experience as a
community health worker.
Qualifying experience is fulfilling the role of a community health worker as outlined in the domains.
The applicant must be currently in the qualifying position at the time of application. Only volunteer positions or
paid employment within the last five (5) years may be counted towards the total experience requirement.
Qualifying work experience can be from multiple organizations to accumulate the required years/hours.
If the applicant’s work experience requirement is not fulfilled from their current organization, they must include
documentation from previous organization(s) verifying their title, duties and dates employed with their
application. DO NOT submit a resume as proof of previous experience. Applicant must contact previous
organizations and request detailed documentation of their experiences from them.
The applicant must be currently volunteering/employed as a community health worker at the time of
application.
CURRENT VOLUNTEER/JOB DESCRIPTION
REQUIRED: Copy of current community health worker volunteer/job description, obtained from current
organization, and which must be signed by both the applicant and their immediate supervisor.
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All applicants must include a copy of their current community health volunteer/job description. This document
is provided by your employer and must be signed and dated by the applicant and their immediate supervisor.
Job descriptions determine and verify eligible current work experience. Job description must clearly delineate
community health services as a primary function of the position.
If you have held different positions with your current employer, please provide all relevant job descriptions
with the application.
In lieu of job description(s), employer may provide an official position description on agency letterhead. This
required documentation must include the applicants’ dates of employment (to/from) employment status (full-
time or part-time), title of position, a detailed description of the duties and responsibilities for the position, and
the average number of hours per week the applicant worked.
ON-THE-JOB SUPERVISION
REQUIRED: 50 hours of on-the-job supervision of qualifying work experience in the
community health worker domains.
While a minimum number of hours per domain is not required, applicants and supervisors are encouraged to
work towards supervision in all domains throughout the span of the CHW’s work/volunteer experience.
Supervision is a formal or informal process that is evaluative, educative, and supportive. It ensures quality of
care and extends over time. Supervision includes observation, mentoring, coaching, evaluating, inspiring, and
creating an atmosphere that promotes self-motivation, learning, and professional development. In all aspects of
the supervision process, ethical and diversity issues must be in the forefront.
RICB has no requirements for who provides supervision. The person providing supervision is at the discretion of
the agency and/or state requirements.
Supervision can be provided in an individual, one-on-one setting and/or observation of skills or group
supervision setting.
Supervision can be provided by more than one supervisor. In this case, provide a copy of page 12 of this
application to all the supervisors documenting supervision on your behalf.
PORTFOLIO
REQUIRED: Documentation and requirements of at least three (3) of the eight (8) categories.
A portfolio is a collection of personal and professional activities and achievements. It is highly personalized, and
no two applicants will submit the same documentation.
Applicants must choose three unique categories. Multiple submissions in one category will only count as
fulfilling one (1) of the three (3) required.
The applicant should submit what they feel best supports and describes their experiences under their chosen
categories. When selecting a category and submitting the documentation, the CHW should use the opportunity
to highlight the value and commitment to not only the profession, but the community served.
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Categories
1. Community Experience & Involvement: Applicant must submit three (3) letters from an organization(s)
that the applicant has volunteered/worked with in one or more of the areas listed. The letters should
clearly describe the applicant’s impact as a CHW and the value added to the community served. When
possible, letters should be on the organization’s letterhead.
a. Leadership experience
b. Board participation
c. Social support and advocacy
d. Education
e. Policy development and promotion
f. Needs assessments
2. Research Activities: Applicant’s must submit a summary of how they participated in the research
activity and supporting documentation. Examples of research activities include:
a. Data collection – qualitative and quantitative
b. Focus groups – either facilitating or participating
c. Panels – either facilitating or participating
d. Surveys – developing, conducting and interpreting data
e. Community mapping/Community resources –finding resources for the population served
f. Dissemination of research – publication and how it was disseminated is required
3. College Level Courses/Advanced or Specialized Training: Applicants that complete education relevant
to the CHW domains, in addition to the 70 hours, must submit documentation and a summary of the
education. Education must be completed within the last 10 years prior to the date of application.
Acceptable forms of education include:
a. College course – a degree does not need to be completed for the course to count
b. Advanced/specialized training - multiple topic areas can be submitted, must total 6 hours
4. Community Publications, Presentations & Projects: Applicants who have completed one or more of the
following should submit documentation and a summary of their participation.
a. Newsletters to the community
b. Poster Presentations
c. Brochure development
d. Curriculum and training development
e. Facilitating trainings
f. Resource guide development
g. Community programming/workshops
h. Promotion: TV, radio, social media, website management, etc.
i. Community event organization and participation
5. Statement of Professional Experience: Respond to one of the following. Answers should be 500 – 1000
words (2-4 paragraphs).
a. Describe a success story you have had in your role as a CHW.
b. What resources (systems, agencies, etc.) have you helped people connect to?
c. Describe your areas of expertise related to community health.
d. Describe how you have applied training as a CHW to your professional life.
e. Briefly describe strengths and opportunities for improvement in your professional life.
f. Describe your motivation to work in community health.
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6. Achievements/Awards: Documentation and summary of the award/achievement received.
a. Recognition from agency, community, advocacy, professional association, etc.
b. Featured in or on TV, radio, print or social media for advancing community health
7. Resume/Curriculum Vitae (CV): Applicants may submit a resume or CV. Resumes should be
professionally formatted. Applicants who need assistance with developing a resume/CV should speak
with their supervisor or use other resources on resume/CV development. All the components below
must be included (if they apply) and must include dates and locations.
a. Relevant work and/or volunteer experience and internships
b. Relevant skills (examples: computer, languages, etc.)
c. Highest level of education completed
d. Other professional certifications
e. Community engagement and fulfillment of community goals
8. Performance Evaluation: Evaluations should highlight the applicant’s abilities as a CHW and must be
completed within two years prior to the application date.
a. Copy of an agency or participant evaluation
b. Statement from supervisor or colleague evaluating the CHW’s performance
c. Documentation of feedback received from the participant or community
d. Capacity building
CERTIFICATION FEE
REQUIRED: $125.00 (fee must accompany certification application)
The fee may be paid by check, money order or with VISA, MasterCard, Discover or American Express.
If an employer or organization is paying the fee, they must include the applicants name with the payment.
Fee payment information provided on page 9 of this application. E-receipts will be sent if using a credit card for
payment. Receipts for check or money order payments must be requested by applicant to RICB.
Applications received without payment will not be processed.
One-half of the fee is refundable if application is denied.
APPLICATION INFORMATION
GENERAL INFORMATION
Email addresses provided to RICB must be active accounts that are checked regularly. We will not be able to contact
you without an email address. Please print legibly.
Applicants must either live or work in RI at the time of application.
APPEAL PROCESS
The purpose of appeal is to determine if RICB accurately reviewed an application that is denied. A letter
requesting an appeal must be sent to RICB within 30 days of the notification of RICB's action. An applicant shall
be considered notified three days after the relevant date of mailing. The appeal will be sent to the RICB
Executive Committee who will thoroughly review the entire application and materials to determine whether or
RICB CCHW Application | www.ricertboard.org | info@ricertboard.org | Revised August 2021
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not applicant should have been denied approval. The applicant will be notified in writing as to the findings of the
Executive Committee.
FELONIES & DISCIPLINARY ACTIONS
While felonies and disciplinary actions from other certification/licensing entities may not prohibit certification,
documentation is required to be submitted at the time of application. Certification through RICB does not mean
a professional should not disclose this information to potential employers and does not in any way exonerate
charges.
REQUESTS TO CHANGE APPLICATION
Professionals who wish to have their application re-reviewed for another credential RICB will incur a $50
application change/review fee.
CERTIFICATION TIME PERIOD
Certification encompasses two calendar years beginning on the date the applicant passes the examination. The
certificate issued to the professional lists the following information: name of professional, credential name, date
of issue, date of expiration and certification number.
RECERTIFICATION
To maintain the high standards of professional practice and to assure continuing awareness of new knowledge
in the field, the Board requires recertification every two years. Professionals should review the Recertification
Application for credential specific requirements listed on the Board website well in advance of their expiration
date.
.
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CCHW: APPLICANT INFORMATION
Application can be completed and saved. You may then print the appropriate pages to submit to RICB.
TYPE OR PRINT LEGIBLY
Today’s Date (mm/dd/yyyy): _________________
Applicant Name: ____________________________________________________________________________________
Print your name as it should appear on your certificate. Credentials and degrees will not be printed.
Date of Birth (mm/dd/yyyy): _________________ SSN (last four): _________________
Have you ever received any disciplinary action from another certification/licensing authority? □ Yes □ No
If yes, provide full details on a separate sheet.
Have you read and understood the RICB Code of Ethical Conduct? □ Yes □ No
The Code of Ethical Conduct is located at www.ricertboard.org/ethics
CONTACT INFORMATION
Home Address:
City:
State:
Zip:
Cell Phone:
Primary Email:
REQUIRED: PRINT LEGIBLY: EMAIL IS OUR PRIMARY WAY OF COMMUNICATING WITH YOU.
Secondary Email:
DEMOGRAPHICS
Data is never released with identifying information. It is used to report workforce data to state and federal agencies.
What is your gender?
□ Female
□ Male
□ Nonbinary
□ Prefer to self-describe: ________________________
□ Prefer not to disclose
Do you identify as transgender?
□ Yes
□ No
□ Prefer not to disclose
How do you describe your sexual orientation or sexual identity?
□ Heterosexual or straight
□ Gay or lesbian
□ Bisexual
□ Queer
□ Questioning or unsure
□ Prefer to self-describe: _________________________
□ Prefer not to disclose
Which best describes you?
□ Asian or Pacific Islander □ Multiracial or Biracial (please specify): _________________________
□ Black or African American □ Not listed (please specify): __________________________________
□ Hispanic or Latino □ Prefer not to disclose
□ Native American or Alaska Native
□ White or Caucasian
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What is your yearly income?
□ Less than $20,000
□ $20,000 to $34,999
□ $35,000 to $49,999
□ $50,000 to $74,999
□ $75,000 to $99,999
□ Over $100,000
□ Unsure
□ Prefer not to disclose
Do you have military experience?
□ Active duty
□ Veteran
□ Not Applicable
Language(s) spoken fluently (check all that apply):
□ American Sign Language
□ Arabic
□ Chinese
□ English
□ French
□ German
□ Indigenous Language
□ Italian
□ Korean
□ Polish
□ Portuguese
□ Russian
□ Spanish
□ Tagalog (Filipino)
□ Vietnamese
□ Other, please specify: _________________________
Employment plans for the next two years (check all that apply):
□ Obtain full time employment/Increase hours
□ Obtain part-time employment/Decrease hours
□ No change
□ Retire
□ Move to a different career/field
□ Unknown
What is the highest degree or level of school you have completed?
(If you’re currently in school, please check the highest degree you have completed.)
□ Less than a high school diploma
□ High school degree or equivalent (e.g. GED)
□ Trade, Technical or Vocational School
□ Some college, no degree
□ Associate degree (e.g. AA, AS)
□ Bachelor’s degree (e.g. BA, BS)
□ Master’s degree (e.g. MA, MS, MEd)
□ Professional degree (e.g. MD, DDS, DVM)
□ Doctorate (e.g. PhD, EdD)
PAYMENT INFORMATION
FEE OF $125 CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to RICB
□ My employer/organization is mailing payment directly to RICB.
□ The following organization will be paying for my application: ______________________________________________
Email for receipt (if paying by credit card only): ________________________________________________________________
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
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CCHW: EDUCATION/TRAINING
REQUIRED: 70 total hours of relevant education/training specific to the
Community Health Worker domains.
I have included copies of training certificates.
□ Yes □ No
I have included a copy of my training tracking system/learning management system report.
□ Yes □ No
My college transcript provides all or some of the relevant education.
□ Yes □ No
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CCHW: EXPERIENCE & VOLUNTEER/JOB DESCRIPTION
REQUIRED: Six (6) months of full-time experience or 1000 hours part-time experience as a
community health worker.
REQUIRED: Copy of current community health worker volunteer/job description, obtained from
current employer, and which must be signed by both the applicant and their immediate supervisor.
CURRENT EMPLOYMENT INFORMATION
Employer Name:
How many hours do you work per week? _______________________________________________________________
Total hours/years worked in current position? ___________________________________________________________
I have attached my current community health worker job description, dated and signed by both me and my
supervisor.
□ Yes □ No
Do you need to document previous employment to fulfill the experience requirement? □ Yes □ No
If yes, complete the section below AND submit a letter (on company letterhead) from previous employer(s) verifying your duties and dates employed
must be included with your application.
PREVIOUS EMPLOYMENT INFORMATION (IF APPLICABLE)
Letter (on company letterhead) from previous employer(s) verifying your title, duties & dates employed must be included with your application.
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Organization Name:
How many hours did you work per week? _______________________________________________________________
Total hours/years worked in previous position? __________________________________________________________
Employer City:
Zip:
Applicant Position/Title:
Start Date in Current Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
Organization City:
Zip:
Applicant Position/Title:
Start Date in Position:
End Date in Position:
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CCHW: ON-THE-JOB SUPERVISION
REQUIRED: 50 hours of on-the-job supervision of qualifying work experience in the
community health worker domains.
Information below is to be completed by applicant’s current and/or previous supervisor(s).
This page is to document the supervision hours provided to the applicant, not their total work hours.
The total hours of supervision should be equal to the hours listed above but could be more depending on the applicants’
length of employment or could be less if the applicant was provided supervision from a previous employer.
Applicants may copy this page and provide it to previous supervisors.
Applicant Name:
SUPERVISOR INFORMATION
Name:
Email:
Phone:
Employer Name:
SUPERVISION DOCUMENTATION
Supervision was provided to the above-named applicant in the following Domains:
DOMAIN:
NUMBER OF HOURS:
□
Engagement Methods & Strategies
□ Individual & Community Assessment
□ Culturally & Linguistically Appropriate Responsiveness
□ Promote Health & Well-Being
□ Care Coordination & System Navigation
□
Public Health Concepts & Approaches
□ Advocacy & Community Capacity Building
□
Safety & Self-Care
□ Ethical Responsibilities & Professional Skills
Supervisor Attestation:
I attest that the above-named applicant has been provided with supervision as documented above.
______________________________________________________ _______________________________________
Supervisor Signature Date
Position/Title:
Licenses, Certifications and/or Degrees:
Employer City:
Zip:
TOTAL NUMBER OF HOURS OF SUPERVISION:
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CCHW: PORTFOLIO CHECKLIST
REQUIRED: Documentation and requirements of at least three (3) of the eight (8) categories.
Applicants must choose three unique categories. Multiple submissions in one category will only count as fulfilling one (1)
of the three (3) required.
Applicant Name:
Indicate which categories you are submitting with your CCHW application.
CATEGORY:
BRIEFLY DESCRIBE TYPE OF DOCUMENTATION INCLUDED
□
Community Experience &
Involvement
□
Research Activities
□
College Level Courses/Advanced
or Specialized Training
□
Community Publications,
Presentations & Projects
□
Statement of Professional
Experience
□
Achievements/Awards
□
Resume/Curriculum Vitae (CV)
□
Performance Evaluation
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CCHW: ACKNOWLEDGEMENTS & RELEASE
This page must be completed by the applicant. It must be notarized and submitted with the application.
RELEASE
I request that the Rhode Island Certification Board (RICB) grant the credential to me based on the following assurances
and documentation:
• I subscribe to and commit myself to professional conduct in keeping with the RICB Code of Ethical Conduct;
• I certify that the information given herein is true and complete to the best of my knowledge and belief. I also
authorize any necessary investigation and the release of information relative to my application;
• Falsification of any documents will nullify this application and will result in denial or revocation of certification;
• I consent to the release of information contained in my application and any other pertinent data submitted to or
collected by RICB to officers, members, and staff of the aforementioned Board;
• I consent to authorize RICB to gather information from third parties regarding education, employment and/or
supervision and understand that such communication shall be treated as confidential;
• Allegations of ethical misconduct reported to RICB before, during, or after application for certification is made
will be investigated by RICB and could result in the nullification of the application or denial or revocation of
certification.
INITIAL EACH STATEMENT
I have read and understood this Acknowledgements and Release.
I either live or work in Rhode Island at least 51% of the time.
I understand one-half of the application fee is refundable if application is denied or cancelled prior to the
examination and no refund will be issued if application is denied or cancelled after examination.
I understand that my application is open for a period of one year after the date of review. If I fail to fulfill all
certification requirements within that year, the application will be closed, and no refund will be issued.
I understand that if I request to have my application re-reviewed for another credential RICB offers prior to
the examination, or after an unsuccessful attempt at the examination I will incur a $50 change/review fee.
Applicant:
Signature:
Date:
PRINT NAME LEGIBLY
NOTARY PUBLIC ONLY
Name:
Date:
I attest that I am a notary public and the above-named applicant satisfactorily proved to be the person whose name is
subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereby set my hand and official seal.
__________________________________________________ SEAL:
Notary Public Signature
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CCHW: CHECKLIST
Applicant Name:
Page must be completed and submitted with the application. Do not submit your application until checklist is
reviewed, completed and all documentation is compiled.
Prior to applying, all requirements must be met and documented. Use the table below as a guide for gathering
documentation.
Do not submit any documentation with an application that is not listed on the table or the application
unless specifically instructed by a staff member. Do not apply until all requirements are met.
TO SUBMIT AN APPLICATION, CHOOSE ONE OF THE FOLLOWING:
1. Mail: RICB, 298 S. Progress Avenue, Harrisburg, PA 17109
2. Email: [email protected]g NOTE: Only PDFs are permitted. Photos of applications are not accepted.
3. Fax: 717-540-4458 NOTE: faxing is an unreliable technology. Receiving a confirmation of fax does not indicate it has been
received. To confirm receipt of application, email info@ricertboard.org
.
I acknowledge, that to the best of my ability, I have submitted a completed application.
Signature:
Date:
REQUIREMENT DOCUMENTATION
✓
Application page with payment
• Page 8 & 9
Formal Education page
• Page 10
Education
• Official college transcript
• Copies of training certificates (if applicable)
Volunteer/Work Experience
• Page 11
• Previous relevant employment documentation
(if needed)
Current job description
• Obtain from employer
Supervision page
• Page 12
Portfolio Checklist
• Page 13
Acknowledgement & Release page
• Page 14, notarized
Checklist page
• Page 15
Disciplinary Actions?
• Include letter of explanation with application
Convicted of a felony?
• Include letter of explanation with application
Company paying fee?
• Include applicant name on payment
Copy entire application for records
