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 ______________

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)

NATIONAL ASSOCIATION OF
VETERANS AFFAIRS CHAPLAINS