Application for NAVAC Board Certified Chaplain

• A person making application for Board Certified
  Chaplain must have the requirements of a Certified
  Clinical Chaplain as prerequisite. A total of 4 units of CPE
  are required.
• Evaluation before a peer review board.
• Annual membership for Board Certified Chaplain
  is $75.00.

NAVAC BOARD CERTIFICATION:
THE APPLICATION PROCESS

• The application for Board Certification is sent to
  the Chairman of the Board of Directors.
• A $100.00 one-time, non-refundable application
  fee is sent to the Treasurer.
• $75.00 in dues is to be paid to the Treasurer on
  the next Jan. 1^st, after acceptance.
• If application is complete, it is sent to Chairman of the Certification Committee.
• A convener is selected, who then selects three Board certified chaplains and up to three persons from other disciplines to serve in the interview process, known
  as the “peer review” (see Section entitled “Role
  of the Convener”).
• Dues paying chaplains from APC, NCVACC,
  NACC, VA Black Chaplains, National
  Association of Jewish Chaplains (NAJC),
  CPE Supervisors, & ACPE – who are Board Certified
  by their own organization, may be
  invited to assist in panels. Only the NAVAC
  members of such panels are voting
  members of the panel.
• A presenter is selected to read all the material and
  to send an outline to all other members; this must
  be done before the peer review (see “Role of
  the Presenter”) If an interview, which may take place
  face-to-face or by video-tel, is positive, the committee informs the candidate of its recommendation, and then notifies the Committee Chairman, who in turn informs
  the Chairman of the Board. Official recognition of acceptance of the candidate as Board Certified
  comes from the Chairman of the Board of Directors.
  All materials are returned to the candidate.
• If the interview is negative, the Interview Panel
  notifies the Chairman of the Certification Committee,
  that….
• Certification is not recommended; OR
• Certification is deferred.
• See the last Section dealing with the
  Appeal Process.

APPLICATION FOR NAVAC
BOARD CERTIFIED CHAPLAIN

1. PERSONAL INFORMATION

Name________________________________ Title_______
Faith Group________________________
Mailing address____________________________________
Work phone_____________________ 
Home phone __________________
FAX __________________
E-mail address___________________________

Current member of NAVAC? ____________

VA Medical Center ___________________________ 

 Position ______________________________

2. EDUCATIONAL BACKGROUND

College_____________________________ Degree________ Date_____________________________

Seminary___________________________ Degree________ Date_____________________________

Further education________________________________

Complete section below if requesting acknowledgement
of equivalency for M.Div:

Institution____________________________Degree________ Date_____________________________

(Send transcript of credits & documentation of theological
education if requesting M.Div. equivalency)

3. ENDORSEMENT

• Endorsed by which faith group?__________________
• Date ___________________
• (provide copy of current endorsement)
• Ordained or commissioned? ________
• When & where______________________________

4. PROVIDE AN AUTOBIOGRAPHY OF YOUR FAITH JOURNEY. (not to exceed 2 typewritten pages)

5. COMPLETE AN UPDATED US GOVERNMENT
FORM OF-612. (not to exceed 5 typewritten pages)

6. COMPLETE A STATEMENT OF THE RATING
FACTORS FOR CHAPLAINS (KSAO’s).

• Please describe your experience, education, training,
  “awards and other specific accomplishments that
  demonstrate your competencies.

Ability to communicate orally and in writing.

Describe your accomplishments in oral and written communication. Describe your use of these abilities in your professional experience
in religious instruction, pastoral care, and participation in
multidisciplinary teams/committees. List and describe
any publications.

Ability to provide pastoral care and counseling in a
healthcare setting.

Describe in detail your experience in providing ministry in
health-care settings. Describe the workplace, the type(s)
of patients or clients served, and your participation as a
member of multidisciplinary treatment team(s). Be sure to
include any experience with veterans. 

List any relevant training or education. Describe your
qualifications in any clinical specialties and attach supporting documentation.

Ability to provide ministry in a pluralistic setting.

Describe your experience in relating with clergy, patients, and
others from various faith and value traditions. Describe any accomplishments in developing interfaith relationships. Describe
your experience in ministering to persons from a variety of
faith groups.

Knowledge of worship principles and practices.

Describe your ministry experience and current professional
practice that demonstrates your knowledge of various worship
(liturgical) principles and practices.

Ability to establish relationships and deal effectively
with others.

Describe your experiences in leading or supervising others. 
Describe your involvement in community and civic activities. 
Be sure to describe your relationships with professional
associations, interdisciplinary teams, veteran’s organizations,
fraternal organizations, etc.

7. PROVIDE EVIDENCE OF PARTICIPATION IN CONTINUING EDUCATION.

8. GIVE A RESUME OF YOUR VA CHAPLAINCY EXPERIENCE.

9. PROVIDE AN ORGANIZATIONAL CHART OF THE SETTING IN WHICH YOU NOW SERVE THE VA.

10. SUPPORTING DOCUMENTS AND CLINICAL
PASTORAL EDUCATION EVALUATIONS:

• -Provide a current letter of ecclesiastical endorsement.
• -Provide a letter from the Supervisor of Chaplains at
  the VA where you are employed.
• -Provide two letters of recommendation from currently
  active NAVAC Board Certified Chaplains.
• -Provide documentation of 4 units of CPE
  or equivalencies.
• -Provide CPE evaluations or equivalencies.
   

• CHAPLAIN TED BLECK-DORAN
  CHAIR, BOARD OF DIRECTORS
  P.O. BOX 787
  MOUNTAIN HOME, TN 37684-0787