Fillable COMMUNITY HEALTH WORKER (CHW) TRAINING ACCREDITATION APPLICATION (Pennsylvania Certification Board)

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COMMUNITY HEALTH WORKER (CHW) TRAINING ACCREDITATION APPLICATION (Pennsylvania Certification Board)

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PCB | CHW Training Accreditation Application | Revised November 2020 1
COMMUNITY HEALTH WORKER (CHW)
TRAINING ACCREDITATION APPLICATION
CHW ACCREDITATION INFORMATION
PCB has established an accreditation process (both full and partial) for organizations who wish to provide CHW
training for initial CHW certification. Candidates applying for the CHW credential must obtain their 75 hours of
training from a PCB accredited organization. Accredited organizations may offer the full 75 or more CHW training
hours or partial (less than 75 hours) CHW training hours.
BENEFITS OF BEING AN ACCREDITED TRAINING ORGANIZATION
• Assured of offering training that candidates for CHW certification must acquire.
• Organization can market trainings as accredited and eligible for certification.
• Accredited training organizations are listed on the PCB website which is the first-place professionals
seeking certification are directed for training. The website is searchable by organization, topic, region,
credential, online or in person training and date.
REQUIREMENTS FOR THE ORGANIZATION
1. Trainings eligible for PCB accreditation must be in the CHW domains.
2. Trainings must use a formal structure.
3. Trainings must occur in Pennsylvania unless the organization is an online provider.
4. Each training must be submitted.
5. Trainings can be submitted any time during the one-year accreditation period.
REQUIREMENTS FOR TRAININGS SUBMITTED
• CV or Resume of trainer(s) must be submitted.
• Copy of the Evaluation Form must be submitted.
• Copy of certificate or transcript provided to the student/participant.
• A draft of any marketing material promoting this training must be submitted.
• Documentation of course/training information including summary, goals, objectives, and a daily schedule (ex:
program documentation, course syllabus, etc.)
• Trainings may be more than the required 75 hours for the CHW credential, but 75 hours is the minimum for full
accreditation.
• Trainings may be less than the required 75 hours for the CHW credential for partial accreditation.
• Trainings can be submitted any time during the one-year accreditation period.
• When calculating hours, exclude breaks.
PCB | CHW Training Accreditation Application | Revised November 2020 2
• Trainings must cover all of the 8 CHW domains listed below for full accreditation:
o Community Health Concepts
o Advocacy and Capacity Building
o Care Coordination
o Health Literacy and Education
o Safety and Self-Care
o Cultural Competency
o Communication and Interpersonal Skills
o Ethical Responsibilities and Professionalism
• Trainings may cover less than the 8 CHW domains for partial accreditation. The provider applying for partial
accreditation may choose how many of the 8 CHW domains they wish to cover.
• Full accreditation: for programs offering 75 hours or more in all 8 CHW domains.
• Partial accreditation: for programs offering less than 75 hours selected from any of the CHW domains.
REQUIREMENTS FOR THE ACCREDITED ORGANIZATION
Provide a certificate of attendance or transcript to each attendee. The certificate or transcript must have the attendee’s
name, the exact title of the training, name of the organization, the date(s) of the training and the total number of hours
awarded to each attendee. Do not change the title or date of the training without notifying PCB in writing. You must
indicate on the certificate that the program is a CHW Accredited Training Program.
If an attendee must leave the training prior to its completion, their certificate of attendance must reflect the exact
amount of time attended. The accredited organization may work with the attendee to assist them in making up any
missed classes/trainings.
ACCREDITATION AGREEMENT TERMS & CONDITIONS
1. The agreement period is one-year.
2. A predetermined, non-refundable fee is set by PCB for the accreditation process; fee is paid at the beginning
of the agreement.
3. Upon review and approval of the agreement, the organization will receive an assigned PCB accreditation
number which will be used and referred to throughout the one-year agreement period.
4. The organization must establish one contact person who will correspond with PCB. This will be the only person
whom PCB will provide information to regarding training approval and is the only person who should submit
training approval applications to PCB.
5. Prior to the end of the agreement year, information on renewing your accreditation will be sent to the contact
person. Renewal process requires submission of any changes to the CHW training program and/or instructors
and annual accreditation fee of $250 for full and $150 for partial accreditation.
PCB | CHW Training Accreditation Application | Revised November 2020 3
CHW ACCREDITATION APPLICATION
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
CHECK ONE: □ Application for full accreditation (75+ hrs.) □ Application for partial accreditation (less than 75 hrs.)
Name:
Email:
Organization:
Website:
I agree to adhere to PCB’s requirements, terms, and conditions for accreditation. Failure to do so could result in
cancellation of accreditation with PCB or the denial of trainings submitted. This agreement is effective for one-year from
date of processing and receipt of payment. I understand the contact person above is the only person who is to submit
accreditation trainings to PCB.
Date:
PAYMENT INFORMATION
PAYMENT (CHECK ONE): □ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
ACCREDITATION LEVEL: □ Full - $250 □ Partial - $150
Email address for receipt (credit card only): _______________________________________________________________
TRAINING INFORMATION
Form can be submitted multiple times throughout the year as trainings are scheduled.
Contact Person:
Email:
Organization:
Title: ______________________________________________________________________________________
The title on your certificate of attendance or transcript must reflect the exact wording above.
Dates of Training(s): ___________________________________________________________________________
Location: _________________________ Total Hours: _______________
Address:
City:
State:
Zip:
Contact Person:
Email:
Number:
-
-
-
Sec. Code:
Name on Card:
Billing address:
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PCB | CHW Training Accreditation Application | Revised November 2020 4
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
Name(s) and Credential(s) of Instructor(s): ___________________________________________________________
ATTACH A SEPARATE SHEET IF MORE INSTRUCTORS NEED TO BE INCLUDED.
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• EMAIL: education@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• FAX: 717-540-4458
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
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Completed 3 June 2021

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