Training Program Information Update Form

DSHS-certified training programs may complete the Training Information Program Update Form below if any updates or corrections are needed.

Name of DSHS-Certified Training Center

Name should match the DSHS certificate for the training center.

Select the Texas Region:

Training Center Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Has this address changed since the training center was certified by DSHS?

Yes

Training Center Contact

Name

Phone

Additional Training Center Contact(s):

Please include name, email, and phone number for all additional Training Center Contact(s).

Type of DSHS-Certified Training Offered

CHW Initial Certification

CHW Instructor Initial Certification

DSHS-Certified CHW Continuing Education

DSHS-Certified CHW Instructor Continuing Education

Language(s) for Training Provided:

English

Spanish

Other:

Name of Person Submitting This Form:

Name

Phone

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