Application for NAVAC Certified Clinical Chaplain
The requirements for Certified Clinical Chaplain conform to the current qualification requirements for employment as a Chaplain for the Department of Veterans Affairs, which are: possession of the degree of Master of Divinity, two units of CPE (Clinical Pastoral Education), and endorsement by a recognized faith body. Equivalencies that are proposed for any of the requirements will be accepted based on the list of equivalencies recognized by the VA National Chaplain Center’s Board of Excepted Service Examiners. Any person who has been accepted as a VA Chaplain, even if grand fathered, qualifies for Certified Clinical Chaplain, based on his/her experience. Any person whose application for Certified Clinical Chaplain is denied may
appeal to the Chairman of the Board of Directors. Annual dues for a person qualifying as a Certified Clinical Chaplain are $50.00, payable in January of each year, and not later than
Mar. 31.
APPLICATION FOR NAVAC
CERTIFIED CLINICAL CHAPLAIN
NAME/TITLE ____________________________________________________
MAILING ADDRESS___________________________________________
WORK PHONE ______________________
HOME PHONE ______________
FAX NUMBER________________
E-MAIL ADDRESS_________________________________
CITIZENSHIP (USA REQUIRED) YES ____ NO ____
ENGLISH LANGUAGE COMPETENCY
FIRST LANGUAGE______OR FLUENT _______
DENOMINATION/FAITH GROUP AFFILIATION______________________________
ECCLESIASTICAL ENDORSEMENT YES __ NO __
DATE ____________
PASTORAL EXPERIENCE (3 years minimum required; attach additional page if needed)
CURRENT MEMBER OF NAVAC YES___ NO___
EDUCATION: DEGREE AND DATE___________________________________
COLLEGE ________________________________________________
SEMINARY ________________________________________________
GRADUATE STUDY ________________________________________________
CERTIFICATION (S)_______________________________
CLINICAL PASTORAL EDUCATION CERTIFICATION:
DATE ________ CENTER________________________
SUPERVISOR ___________________
DATE ________ CENTER________________________
SUPERVISOR ___________________
DATE _________ CENTER________________________
SUPERVISOR ___________________
DATE _________ CENTER _______________________
SUPERVISOR ___________________
BESE EQUIVALENT(S) FOR CPE
DATE ___________CENTER ________________________
SUPERVISOR ____________________
Please write a paragraph that provides your understanding of the integrating of technology used by VA (computer charting, inpatient and outpatient encounter forms/event capture, and Computerized Patient Record System –CPRS) and the delivery of quality pastoral care.
Please write a paragraph describing your experience and the use of spiritual assessments in conjunction with interdisciplinary team planning
of patient treatments.
(WHEN COMPLETED, REMIT WITH ANNUAL
DUES OF $50.00)
NAVAC Certification Committee Chair
Chaplain Thomas Mills (2014)
VA Illiana HCS
1900 East Main Street
Danville, IL 61832-5198
E-Mail: Thomas.Mills@va.gov
