|
Facilitator Application Form
To apply to be an Iowa Living Well facilitator,
please complete the form below.
This form is also
available in MS Word format, if you prefer to fill it out on
paper.
For questions or information about the
process, please contact
Mike Hoenig by
email, or phone 319-353-6448.
First name Middle initial
Last name
Street
address Apartment no.
City State ZIP+4
Home phone
Best days and times to call you
at home:
Do you take calls at work?
YES
NO
If YES, work
phone
Best days and times to call you
at work:
E-mail address (if available):
_____________________________________
Please keep your answers as brief and to the point as
possible as you repond to the questions below.
NOTE: Please remember online forms may not be
secure. If you want to share information that is confidential,
please download and complete the
print version of this
application.
1. Why do you want to be a certified facilitator
for Living Well Iowa?
2. How would you describe yourself? List three
traits that best
describe you, such as creative, quiet,
caring, etc.:
1.
2.
3.
3. Do you identify yourself as a
person with disabilities?
NO
YES If YES, what are your disabilities?
4. Describe your knowledge of
disability issues and your involvement
with Iowa’s disability
community:
5.
What is “People First” language? Why is it important to use People
First language?
6. How do you stay abreast of health
and wellness issues related
to people with disabilities:
7. Do you have a current teaching certificate?
NO
YES
If YES, what age range, subject areas, etc.?
8. What is your educational background
-- diplomas,
degrees, subject
areas, certificates, etc.?
9. What is your employment
experience related to disability, health, and
facilitating groups?
10. What is your volunteer
experience related to disability, health, and
facilitating groups?
11. Describe your organizational
abilities and follow-through skills:
12. How comfortable are you speaking in front of
groups?
(Please check only one response.)
I can speak comfortably off the top of my head
(extemporaneously).
I can speak comfortably in front of groups if I
have notes.
I
am OK if I am well prepared; I must study and
practice.
I get “butterflies” every time I speak in groups.
13. How would you handle problems with logistics
or
emergencies if
you were in charge?
(Please check only
one response.)
I would go with the flow and adapt as needed.
I would get flustered, but manage to do OK.
I
would turn to others for answers.
I would tend to fall to pieces if things don’t go
right.
14. Describe your experience facilitating groups:
Topics, type of
groups, how large of groups, etc. Please be
specific.
|
Questions 15
through 29 are designed to help us assess your capacity to
be a facilitator.
We base support and training opportunities on your answers.
Please answer by choosing the number that best describes your
skills.
|
15. How familiar are you with general health and wellness
issues?
(Please check only one response.)
I am an
expert in this area.
I am very familiar and comfortable with this.
I’ve done this before, but need more experience.
I've never done this before, but I am willing to learn.
I am not at
all comfortable with this.
This does not apply to me or my situation.
|
|
16.
How familiar are you with health and wellness issues
specific to
people who have disabilities other than your
own?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I am not at
all comfortable with this.
This
does not apply to me or my situation.
|
|
17.
How familiar are you with Iowa’s service delivery system?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
18.
How familiar are you with federal programs
used by people with
disabilities, such as like SSI, SSDI,
Voc Rehab, Title 19, and
Medicare?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
19.
How familiar are you with state information resources, such
as
Iowa COMPASS, InfoTech, and the DRL?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
20
How familiar are you with the local resources in your
community,
such as service providers, professionals, and
general services?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
21.
How familiar are you with using the Internet to find
information on
health and disability issues?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
22.
How much personal experience do you have with people
whose
disabilities are different than yours?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
23.
How much experience do you have -- through work,
volunteering,
or life -- with people who have challenging
behaviors or difficult
personalities?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
24.
How much experience do you have -- through work,
volunteering,
or life -- with arranging conferences,
trainings, or workshops?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
25.
How much experience do you have -- through work,
volunteering,
or life -- with recruiting people to
attend conferences, trainings,
or workshops?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
26.
How much leadership experience do you have, such as being
the
president of an organization, chairperson of a
committee, or
representing “consumers” on a task force?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
27.
How much experience do you have -- through work,
volunteering,
or life -- with facilitating training
sessions or teaching adults?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
28.
How much experience do you have -- through work,
volunteering,
or life -- with following and
implementing a teaching or training
curriculum?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
29. How much
experience do you have -- through work,
volunteering, or life -- with
modifying a curriculum “on the fly”
during an actual training session?
(Please check only one response.)
I
am an expert in this area.
I
am very familiar and comfortable with this.
I’ve
done this before, but need more experience.
I've
never done this before, but I am willing to learn.
I
am not at all comfortable with this.
This
does not apply to me or my situation.
|
|
30. What
additional information or training opportunities do you
need in order to be an effective facilitator?
|
|
31. What
accommodations do you need in order to be an effective
facilitator?
|
|
Click
to send us your application
Click
to erase all your answers in order to start
over
Thank you!
Living Well With A Disability Facilitator Application
Approved by the LWD Advisory Committee – 4/30/02
|
|
| 
| 
| 
|
| 
| 
|
|