Community Health Worker -- Experience Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF EXPERIENCE
Applicant's Name*
First and Last Name
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TO BE COMPLETED BY EMPLOYER
Name of Employer

First NameLast Name
Dates Applicant of experience in community health work: From *

MonthDayYear
To *

MonthDayYear
Total number of HOURS of experience completed:*
Number of Hours
For purposes herein, community health worker means a public health outreach professional with an in-depth understanding of the experience, language, culture and socioeconomic needs of the community and who provides a range of services, including, but not limited to, outreach, engagement, education, coaching, informal counseling, social support, advocacy, care coordination, research related to social determinants of health and basic screenings and assessments of any risks associated with social determinants of health.
YesNo
If yes, please explain: (attach additional sheet if necessary) *
Enter Explanation
I certify that I am authorized by this agency to provide official verification of employment and that the information contained herein is true and accurate and is based on documentation maintained by this agency. I further certify that the number of hours reported was experience in community health worker duties as defined above.
Signature of Authorized Representative *
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date *

MonthDayYear
Printed Name of Authorized Representative *
Enter First and Last Name
Title of Authorized Representative *
Title of Authorized Representative
Name of Agency

Name of Agency

Street Address Line 2

CityState / Province

Postal / Zip Code
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please provide this completed form to the applicant named above. The applicant will upload an electronic image of this document as part of their application for certification as a community health worker.
Should be Empty:

STATE OF CONNECTICUT

VERIFICATION OF EXPERIENCE