Registration Form

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One Key Question® Training Interest Form

This form is to sign up for One Key Question® offered free of charge to community health workers and doulas in the state of Arkansas by UAMS Institute for Community Health Innovation during Spring, Summer, and Fall of 2026.
By participating in training and follow up surveys, you will be eligible to receive compensation for your time in the way of digital gift cards

Enrollment and Compensation Information:
Instructions on enrolling in One Key Question training, follow up surveys, and gift cards will be sent to the email you provide in this form. Compensation amounts are outlined below:
• $300 upon completion of training and training evaluation survey
• $100 upon completion of 2-month follow up evaluation survey
• $150 upon completion of 6-month follow up evaluation survey
Please complete One Key Question® training within 30 days of receiving your email from
Power to Decide.
UAMS Project Manager, Chelsea Barker (cbarker3@uams.edu) can be contacted with any
questions.
Thank you for your interest!

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

First name:

* must provide value

Last name:

* must provide value

Please provide an email address. This email will be used to send information regarding the One Key Question registration, evaluation surveys, and gift cards.

* must provide value

Phone number:
We will only contact you via phone if we have trouble registering your email.

* must provide value

Which one of these bests describes your job function?

* must provide value

CHW

Doula

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What percent of your job currently involves supporting or educating females aged
15-55 in their health needs? (Please estimate to the best of your ability.)

* must provide value

1%-24%

25-49%

50-74%

75-100%

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Which county do you reside in?

* must provide value

Other County outside Arkansas

* must provide value

Which county(ies) do you primarily serve?

* must provide value

How would you describe your empower employer type.

Independent/self-employed

Hospital

Clinic

Federally Qualified Health Center (FQHC)

Community based organization or non-profit

Other:

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Which one or more of the following would you say is your race or ethnicity? Please choose all that apply.

* must provide value

Hispanic, Latino/a, or Spanish origin

White

Black/African American

American Indian or Alaska Native

Asian

Pacific Islander

Other

I don't know/not sure

I prefer not to answer

If other ethnicity specify

* must provide value

How do you describe your gender?

* must provide value

Male

Female

I prefer to self-describe

I prefer not to answer

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Please provide an estimate of how many clients/patients do you serve each year

* must provide value

How did you hear about this training? (If possible, please include the specific organization or mailing list) *

* must provide value

Expand

I understand that by submitting this form, I am communicating my interest in completing One Key Question® training. If I am enrolled, I understand that it is expected that I complete training within 30 days, and I will not recieve compensation until completing the required activities as outlined above.

* must provide value

Yes

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Completed OKQ enrollment through Power to Decide?

Yes

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Is the training complete

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.