Community Health Consultant Application

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This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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Required format:

nMz59GE8tLN2G7wDg93d8A6YQGN95cEIVadguNhtdVH9pFx765FCGZenGedcPIzQVL3snw5iXbg9Jey57v

We are focused on improving health in our communities by listening and responding to individuals with diverse lived experiences. Lived experiences include things like health conditions, your age, race or ethnicity, social or professional identity, and/or neighborhood involvement.

We ask individuals in our St. Louis and rural Missouri communities to serve as Community Health Consultants based on their lived experiences. These paid roles vary in structure and time commitment. For example, one opportunity may be for a one-time 90-minute virtual meeting to provide a health researcher with feedback; another may be a 2-year advisory group that meets a few times a year. Each role is rooted in making sure community voice is elevated, heard and respected.

The information requested in this form will be kept secure and will not be shared directly with researchers or anyone outside of our Center.

By completing this form I understand that the information I provide about me will be kept confidential and is not being collected for research purposes. Please note: WU employees are not currently eligible to participate as community health consultants.

Thank you for your commitment to the health of individuals in our community.

Please contact Hilary Broughton, hilary.broughton@wustl.edu if you have any questions.

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Where did you hear about the community health consultant program?

Please describe Other

First Name

Last Name

Street Address

City

State

Other state

ZIP Code

Phone

Other Phone

Please check your preferred method of contact

Call

Text

Birth Month/Year

Date of Birth

M-D-Y

Gender

Please describe

Calculated Age DOB

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Date of Death

D-M-Y

Race/Ethnicity

American Indian/Alaska Native

Asian American

Black/African American

Caucasian

Native Hawaiian/Other Pacific Islander

Other

Unknown

Please describe Other

Hispanic, Latino, Spanish Origin?

Yes

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Are you currently employed?

Yes

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Name of employer

Zip code(s) where you primarily work?

Job title

Are you involved in any of the following community groups or associations?
(check all that apply)

Neighborhood associations/leadership council

Parent Teacher Organizations/Associations

Resident associations

Senior living community groups

Issue or disease focused community coalition or advocacy group

Faith-based institutions

Other

Please describe Other

Have you participated in the Community Research Fellows Training Program at Washington University in St. Louis?

Yes

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Are you interested in learning about community researcher training?

Yes

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Are you a certified Community Health Worker in Missouri?

Yes

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What topics do you have lived experience with? By lived experience, we mean that you personally or someone you provide care for identifies with the condition or barrier.
(check all that apply)

Aging/dementias (ex: memory loss, mobility loss)

Asthma

Autoimmune disease

Cancer

Child health

Chronic pain

Community health care provider

Diabetes

Difficulties accessing health care

Genetic Testing

Gun violence

Heart disease (ex: heart attack, high blood pressure)

HIV/AIDS

Intellectual disabilities (ex: autism spectrum disorder)

LGBTQ+ health

Mental health (ex: anxiety, depression)

Occupational health (ex: factory, farmer)

Physical disabilities

Rural health

Social service provider (ex: case manager)

Substance use/abuse

Tobacco use

Weight/Obesity

Women's health

Other

Please describe Other

How would you describe your availability/time commitment?

In addition to community health consultant opportunities, do you want to hear about upcoming events and activities through our Center for Community Health Partnership & Research monthly newsletter?

______

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