School Based Community Health Workers

Thank you for taking the time to complete this survey about Telehealth ROCKS’ School-Based Community Health Worker (CHW) program. Your feedback will help demonstrate the program’s impact and value. Survey results will also support efforts to sustain and expand the program so more students can benefit in the future.

1. What is your level of familiarity with the school-based community health worker (CHW) program?

2. How do you interact with school-based CHWs in your setting? (Select all that apply)

I am a school-based CHW
I interact with a student referred to the CHW and/or their family
I refer students to the CHW
I interact with the CHW related to student needs
I support health care coordination (for example, Medicaid enrollment, access to care)
I support non-medical service coordination (for example, community-based referrals, housing support, sanitation services)
I provide non-medical supports (for example, free/low-cost food or clothing, arraange services, enrollment in programs)
Other (Please Specify) Please enter an 'other' value for this selection.

2. Thinking about a single typical encounter around a student's need, for each activity below, approximately how long does it last?

Space Cell	Less than 30 minutes	30-60 minutes	60-90 minutes	90-120 minutes	More than 2 hours	Not applicable/Don't know
Direct interaction with student and/or family	Direct interaction with student and/or family: Less than 30 minutes	Direct interaction with student and/or family: 30-60 minutes	Direct interaction with student and/or family: 60-90 minutes	Direct interaction with student and/or family: 90-120 minutes	Direct interaction with student and/or family: More than 2 hours	Direct interaction with student and/or family: Not applicable/Don't know
Interaction with non-CHW school personnel (teachers, administrators, school counselors)	Interaction with non-CHW school personnel (teachers, administrators, school counselors): Less than 30 minutes	Interaction with non-CHW school personnel (teachers, administrators, school counselors): 30-60 minutes	Interaction with non-CHW school personnel (teachers, administrators, school counselors): 60-90 minutes	Interaction with non-CHW school personnel (teachers, administrators, school counselors): 90-120 minutes	Interaction with non-CHW school personnel (teachers, administrators, school counselors): More than 2 hours	Interaction with non-CHW school personnel (teachers, administrators, school counselors): Not applicable/Don't know
Social services coordination (phone calls, emails, travel, in-person meetings)	Social services coordination (phone calls, emails, travel, in-person meetings): Less than 30 minutes	Social services coordination (phone calls, emails, travel, in-person meetings): 30-60 minutes	Social services coordination (phone calls, emails, travel, in-person meetings): 60-90 minutes	Social services coordination (phone calls, emails, travel, in-person meetings): 90-120 minutes	Social services coordination (phone calls, emails, travel, in-person meetings): More than 2 hours	Social services coordination (phone calls, emails, travel, in-person meetings): Not applicable/Don't know
Enter another option	Other: Less than 30 minutes	Other: 30-60 minutes	Other: 60-90 minutes	Other: 90-120 minutes	Other: More than 2 hours	Other: Not applicable/Don't know

2. Thinking about a typical student you support over the course of a school year, estimate the total time you spend across each of the categories below?
This includes time directly interacting with the student and/or family, conversations with teachers and other school personnel, and time identifying and arranging needed resources.

Space Cell	Less than 2 hours	2-5 hours	6-10 hours	11-20 hours	21-40 hours	More than 40 hours
Direct interaction with student and/or family	Direct interaction with student and/or family: Less than 2 hours	Direct interaction with student and/or family: 2-5 hours	Direct interaction with student and/or family: 6-10 hours	Direct interaction with student and/or family: 11-20 hours	Direct interaction with student and/or family: 21-40 hours	Direct interaction with student and/or family: More than 40 hours
Interaction with non-CHW school personnel (teachers, administrator, school counselors)	Interaction with non-CHW school personnel (teachers, administrator, school counselors): Less than 2 hours	Interaction with non-CHW school personnel (teachers, administrator, school counselors): 2-5 hours	Interaction with non-CHW school personnel (teachers, administrator, school counselors): 6-10 hours	Interaction with non-CHW school personnel (teachers, administrator, school counselors): 11-20 hours	Interaction with non-CHW school personnel (teachers, administrator, school counselors): 21-40 hours	Interaction with non-CHW school personnel (teachers, administrator, school counselors): More than 40 hours
Social services coordination (phone calls, emails, travel, in-person meetings)	Social services coordination (phone calls, emails, travel, in-person meetings): Less than 2 hours	Social services coordination (phone calls, emails, travel, in-person meetings): 2-5 hours	Social services coordination (phone calls, emails, travel, in-person meetings): 6-10 hours	Social services coordination (phone calls, emails, travel, in-person meetings): 11-20 hours	Social services coordination (phone calls, emails, travel, in-person meetings): 21-40 hours	Social services coordination (phone calls, emails, travel, in-person meetings): More than 40 hours
Enter another option	Other: Less than 2 hours	Other: 2-5 hours	Other: 6-10 hours	Other: 11-20 hours	Other: 21-40 hours	Other: More than 40 hours

2. How do CHWs support your school/district? (Select all that apply)

2. Approximately how many students have you personally referred to or directly connected with a school-based CHW in the past year?