Tool Box for Human Resources Specialists:

*Filling Staff Chaplain Positions*

Prepared by John J. Batten, Program Analyst, National VA Chaplain Center

October, 2006

Contents

a\. Appointing Authority

b\. External Hiring Procedures

c\. Merit Promotion

d\. Contract/Fee-Basis Chaplains

e\. Trainees

f\. Ecclesiastical Endorsements

##### Appendices

\(1\) Sample merit promotion announcement for staff chaplain

\(2\) Contract Statement of Work for Chaplain

\(3\) Sample Request for Referral of Eligibles from the Board of
Excepted

Service Examiners

\(4\) Procedure for requesting verification of qualifications of
contract or

> fee-basis chaplain

**a. Appointing Authority:** Chaplains are employed in the Title 5
excepted service under Schedule A 213.3102a.[^1] (reference: Schedule A
213.3102a.)

**b. External Hiring:**

**(1) Applicant examining**

The Board of Excepted Service Examiners (BESE) for Chaplains at the
National VA Chaplain Center, Hampton, Virginia performs all applicant
examining for VA chaplains. \[reference VA Handbook 5005, Part II,
Section C, Paragraph 6d(1) and 6d(1)(b)\]

**(2) Appointments**

All permanent VA chaplains are appointed from certificates issued by the
BESE \[reference VA Handbook 5005, Part II, Section C, Paragraph
6c(1)\]. This includes selection of chaplains from another federal
agency or department, re-hire of a chaplain formerly employed in VA or
another federal agency/department, selection of a permanent VA employee
in a different occupation, and non-competitive appointments as allowed
by law and regulation. \[reference VHA Handbook 1111.2, Paragraph
22c(1)(a)\]

**(3) Non-competitive Appointments**

The Board of Excepted Service Examiners will issue certificates of
eligibles without numerical rating and ranking in the following cases:

\(a\) Individuals who have completed a one-year Clinical Pastoral
Education residency or fellowship in a VA health care facility, and who
meet all minimum qualification requirements. **Note** that these
individuals must be considered in order of veteran preference.
\[reference VHA Handbook 1111.2, Paragraph 22c(6)\]

\(b\) A person who previously held a permanent VA chaplain position may
be rehired in the same commuting area and at the same or lower grade as
the position last held, provided that there are no candidates eligible
for the position on the VA Priority Reemployment List. \[reference 5 CFR
Sec. 302.101c(10)\]

\(c\) A persons who previously held a permanent VA chaplain position and
who has veteran preference may be reappointed at the same or lower grade
at any location. (reference 5 CFR Sec. 302.402)

**(4)** **Other Excepted Appointing Authorities**

Chaplains may **[not]{.underline}** be appointed under other competitive
or excepted service authorities, including VRA, VEOA, and schedule A
authorities. (reference: HRM Conference Call April 14, 2004)

**(5)** **Temporary and Time-Limited Appointments**

Facility Directors may make temporary and time-limited appointments of
chaplains without BESE announcement and evaluation of the applicants.
\[reference VHA Handbook 1111.2 Chapter 22c(5)\] Time-limited
appointments may be made for more than one year. \[reference 5 CFR Sec.
213.104(a)(1)\]

**(6) Requesting Referral of Eligibles from the Board of Excepted
Service Examiners**

The Human Resources Office serving a facility may request certificates
of eligibles for chaplain positions by sending, or faxing, SF-39,
"Request for Referral of Eligibles," to the address given below. There
is no cost for certificates from the BESE. A copy of the position
description must accompany the request.

National VA Chaplain Center (301/111C)

Veterans Affairs Medical Center

100 Emancipation Drive, Building 33

Hampton, VA 23667

**(7) Selective and Quality Rating Factors**

\(a\) When a position requires the chaplain to meet the religious and
sacramental needs of a particular major faith group (e.g. Roman
Catholic, Protestant, Jewish, Islamic, etc) this must be indicated on
the SF-39. Restriction of consideration to one major faith group is a
selective factor (see "Use of Selective Factors" in the Chaplain
Qualification Standard, VA Handbook 5005, Part II, Appendix F1). The
position description for the position must justify the selective factor
and must show the appropriate competitive level code in block 13 of the
cover sheet OF-8.

\(b\) Other selective and/or quality rating factors may be requested on
SF-39A. It is strongly recommended that the facility Human Resources
office consult with the National Chaplain Center prior to requesting
selective and quality factors. The Director, Chaplain Service is the
approving authority for selective/quality rating factors and for passing
over or objecting to eligibles on BESE certificates. \[reference VHA
Handbook 1111.2 Chapter 22 Paragraph 22c(3)\]

\(c\) Facilities may submit name-requests for applicants on the SF-39 in
the same way they would for other requests for referral of eligibles.

**(8) Rule of Three**

Selection from certificates of numerically rated and ranked applicants
must be made in accordance with the "rule of three" that applies to
selection for competitive service positions \[reference 5 CFR Sec.
302.401(a)\]

**(9) Length of Validity of BESE Certificates**

BESE certificates expire 90 days after the date of issue. Extensions
beyond 90 days cannot be granted. Once a properly prepared BESE
certificate is issued, BESE will not issue another certificate for the
same vacancy (same location, major faith group, grade, grade potential,
work schedule) for 90 days after the date of issue unless one of the
following occurs:

-   There are fewer than 3 applicants available

-   A new request is submitted with justified selective and/or quality
    rating factors

-   The facility is authorized additional identical positions

-   The facility demonstrates that the applicants referred do not meet a
    legitimate need for diversity in accordance with the Federal Equal
    Opportunity Recruitment Program (FEORP)

**c. Merit Promotion**

VA facilities may fill chaplain positions by promotion, reassignment and
change to a lower grade of current VA chaplains in accordance with
national and local merit promotion policies. When numerical rating of
merit promotion applicants is required the Board of Excepted Service
Examiners acts as a promotion panel.

**d. Contract and Fee-basis Personnel**

VA facilities may make fee-basis appointments of chaplains and utilize
chaplains under contract under the same policies that apply to other
professional health care providers. To describe contract work and the
required qualifications of individuals facilities can use the attached
Statement of Work (SOW).

Contract and fee-basis chaplains must meet all qualification
requirements for VA chaplain. (reference VA Handbook 5005, Part II
Appendix F1). Each contract and fee-basis chaplain must be certified as
meeting minimum qualification requirements by the BESE prior to
performing any work. (reference: VHA Handbook 1111.2 Paragraph 16d) The
procedure for requesting certification is appendix 4.

When qualified chaplains are not available to meet patient care needs,
non-chaplains may be used to perform specific tasks. For example, Roman
Catholic Extraordinary Ministers of Holy Communion (Eucharistic
Ministers) may, when properly commissioned, provide specific ministry
services to Roman Catholic patients. **In no case may such individuals
be used in lieu of qualified chaplains. Care must also be taken to
ensure that such individuals are not portrayed as, or perceived as,
chaplains**. Before using the services of such individuals contact the
National Chaplain Center to assure that faith-specific requirements are
met.

**e. Students**

VA facilities may appoint trainees in affiliated Clinical Pastoral
Education (CPE) programs under authority of 38 USC 7405(a)(1)(D).  For
information on affiliations and funding see the Associated Health
Professions Handbook, Academic Affiliation (M-8, Part II, Chapter 2),
and the annual program announcements for trainee support in associated
health professions.

VA facilities may appoint students enrolled in a baccalaureate, masters
or doctoral program accredited by the Association of Theological Schools
in the United States and Canada; the United States Catholic Conference
Commission on Certification and Accreditation; American Association of
Bible Colleges; or Association of Advanced Rabbinical Talmudic Schools.
These students are given without compensation appointments in accordance
with an affiliation agreement with the educational institution. Examples
include students receiving supervised ministry experience in a Master of
Divinity program, and students in a Clinical Pastoral Orientation
course.

Facilities must inform students in writing at the time of their
appointment about the qualification requirements for employment as a VA
chaplain, and, if applicable, about their eligibility upon completion of
training for non-competitive consideration for employment through the
Board of Excepted Service Examiners.

**f. Ecclesiastical Endorsements**

Ecclesiastical endorsements for VA Chaplain positions must be signed by
the properly designated [national]{.underline} endorsing official of a
religious faith group. (Reference Chaplain Qualification Standard and
VHA Handbook 1111.1 "Ecclesiastical Endorsing Organizations.") The
National Chaplain Center keeps a current list of ecclesiastical
endorsing officials.

Most faith groups issue ecclesiastical endorsements that are valid
indefinitely for work at any VA facility. However, faith groups may
elect to issue time-limited endorsements, and/or endorsements valid only
for certain work schedules and/or locations. For movements of chaplains
within VA an endorsement dated within the past year is not required.
However, Human Resources Offices are responsible for assuring that the
endorsement of record is valid for the location and work schedule of the
position to be filled.

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| NO.       |           |   | GRADE   | RANGE |   | ITIONS | POT    |
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| on a      |           |   |         |       |   |        |        |
| cas       |           |   |         |       |   |        |        |
| e-by-case |           |   |         |       |   |        |        |
| basis.*   |           |   |         |       |   |        |        |
+-----------+-----------+---+---------+-------+---+--------+--------+
| REMARKS   |           |   |         |       |   |        |        |
| This      |           |   |         |       |   |        |        |
| position  |           |   |         |       |   |        |        |
| is in the |           |   |         |       |   |        |        |
| excepted  |           |   |         |       |   |        |        |
| service   |           |   |         |       |   |        |        |
| under     |           |   |         |       |   |        |        |
| Schedule  |           |   |         |       |   |        |        |
| A         |           |   |         |       |   |        |        |
| 2         |           |   |         |       |   |        |        |
| 13.3102a. |           |   |         |       |   |        |        |
| The tour  |           |   |         |       |   |        |        |
| of duty   |           |   |         |       |   |        |        |
| is:[\_\   |           |   |         |       |   |        |        |
| _\_\_\_\_ |           |   |         |       |   |        |        |
| ]{.mark}. |           |   |         |       |   |        |        |
| ([If      |           |   |         |       |   |        |        |
| app       |           |   |         |       |   |        |        |
| licable): |           |   |         |       |   |        |        |
| This      |           |   |         |       |   |        |        |
| position  |           |   |         |       |   |        |        |
| requires  |           |   |         |       |   |        |        |
| on-call   |           |   |         |       |   |        |        |
| duty      |           |   |         |       |   |        |        |
| ]{.mark}. |           |   |         |       |   |        |        |
| respons   |           |   |         |       |   |        |        |
| ibilities |           |   |         |       |   |        |        |
+-----------+-----------+---+---------+-------+---+--------+--------+
| **        |           |   |         |       |   |        |        |
| DUTIES**: |           |   |         |       |   |        |        |
| The       |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| assesses  |           |   |         |       |   |        |        |
| r         |           |   |         |       |   |        |        |
| eligious, |           |   |         |       |   |        |        |
| s         |           |   |         |       |   |        |        |
| piritual, |           |   |         |       |   |        |        |
| moral,    |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| ethical   |           |   |         |       |   |        |        |
| problems  |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| patients  |           |   |         |       |   |        |        |
| and plans |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| provides  |           |   |         |       |   |        |        |
| ap        |           |   |         |       |   |        |        |
| propriate |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| care,     |           |   |         |       |   |        |        |
| including |           |   |         |       |   |        |        |
| i         |           |   |         |       |   |        |        |
| ndividual |           |   |         |       |   |        |        |
| in-depth  |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| ministry  |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| co        |           |   |         |       |   |        |        |
| unseling. |           |   |         |       |   |        |        |
| He/she    |           |   |         |       |   |        |        |
| par       |           |   |         |       |   |        |        |
| ticipates |           |   |         |       |   |        |        |
| actively  |           |   |         |       |   |        |        |
| on        |           |   |         |       |   |        |        |
| interdis  |           |   |         |       |   |        |        |
| ciplinary |           |   |         |       |   |        |        |
| team      |           |   |         |       |   |        |        |
| s/groups, |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| c         |           |   |         |       |   |        |        |
| ommittees |           |   |         |       |   |        |        |
| to assure |           |   |         |       |   |        |        |
| that the  |           |   |         |       |   |        |        |
| religious |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| spiritual |           |   |         |       |   |        |        |
| d         |           |   |         |       |   |        |        |
| imensions |           |   |         |       |   |        |        |
| of health |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| wellness  |           |   |         |       |   |        |        |
| are       |           |   |         |       |   |        |        |
| addressed |           |   |         |       |   |        |        |
| in all    |           |   |         |       |   |        |        |
| aspects   |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| medical   |           |   |         |       |   |        |        |
| center's  |           |   |         |       |   |        |        |
| holistic  |           |   |         |       |   |        |        |
| patient   |           |   |         |       |   |        |        |
| care. The |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| also      |           |   |         |       |   |        |        |
| provides  |           |   |         |       |   |        |        |
| counsel   |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| support   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| relatives |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| patients  |           |   |         |       |   |        |        |
| in        |           |   |         |       |   |        |        |
| difficult |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| trying    |           |   |         |       |   |        |        |
| s         |           |   |         |       |   |        |        |
| ituations |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| alleviate |           |   |         |       |   |        |        |
| their     |           |   |         |       |   |        |        |
| a         |           |   |         |       |   |        |        |
| nxieties, |           |   |         |       |   |        |        |
| and to    |           |   |         |       |   |        |        |
| help them |           |   |         |       |   |        |        |
| deal with |           |   |         |       |   |        |        |
| grief and |           |   |         |       |   |        |        |
| ber       |           |   |         |       |   |        |        |
| eavement. |           |   |         |       |   |        |        |
| The       |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| responds  |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| em        |           |   |         |       |   |        |        |
| ergencies |           |   |         |       |   |        |        |
| or crises |           |   |         |       |   |        |        |
| when      |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| care is   |           |   |         |       |   |        |        |
| app       |           |   |         |       |   |        |        |
| ropriate. |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| The       |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| will      |           |   |         |       |   |        |        |
| determine |           |   |         |       |   |        |        |
| the need  |           |   |         |       |   |        |        |
| for and   |           |   |         |       |   |        |        |
| provide   |           |   |         |       |   |        |        |
| regular   |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| special   |           |   |         |       |   |        |        |
| worship   |           |   |         |       |   |        |        |
| services, |           |   |         |       |   |        |        |
| at times  |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| locations |           |   |         |       |   |        |        |
| such that |           |   |         |       |   |        |        |
| all       |           |   |         |       |   |        |        |
| patients  |           |   |         |       |   |        |        |
| will have |           |   |         |       |   |        |        |
| access.   |           |   |         |       |   |        |        |
| The       |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| will      |           |   |         |       |   |        |        |
| perform   |           |   |         |       |   |        |        |
| s         |           |   |         |       |   |        |        |
| acraments |           |   |         |       |   |        |        |
| and/or    |           |   |         |       |   |        |        |
| rituals   |           |   |         |       |   |        |        |
| to meet   |           |   |         |       |   |        |        |
| the       |           |   |         |       |   |        |        |
| unique    |           |   |         |       |   |        |        |
| needs of  |           |   |         |       |   |        |        |
| (fill in  |           |   |         |       |   |        |        |
| as        |           |   |         |       |   |        |        |
| ap        |           |   |         |       |   |        |        |
| plicable: |           |   |         |       |   |        |        |
| Pr        |           |   |         |       |   |        |        |
| otestant, |           |   |         |       |   |        |        |
| Roman     |           |   |         |       |   |        |        |
| Catholic, |           |   |         |       |   |        |        |
| Jewish,   |           |   |         |       |   |        |        |
| Eastern   |           |   |         |       |   |        |        |
| Orthodox, |           |   |         |       |   |        |        |
| Islamic,  |           |   |         |       |   |        |        |
| or other  |           |   |         |       |   |        |        |
| major     |           |   |         |       |   |        |        |
| faith     |           |   |         |       |   |        |        |
| group)    |           |   |         |       |   |        |        |
| patients. |           |   |         |       |   |        |        |
| When      |           |   |         |       |   |        |        |
| patients  |           |   |         |       |   |        |        |
| have      |           |   |         |       |   |        |        |
| needs     |           |   |         |       |   |        |        |
| that the  |           |   |         |       |   |        |        |
| chaplain  |           |   |         |       |   |        |        |
| cannot    |           |   |         |       |   |        |        |
| meet,     |           |   |         |       |   |        |        |
| he/she    |           |   |         |       |   |        |        |
| will      |           |   |         |       |   |        |        |
| locate    |           |   |         |       |   |        |        |
| other     |           |   |         |       |   |        |        |
| staff     |           |   |         |       |   |        |        |
| chaplains |           |   |         |       |   |        |        |
| or clergy |           |   |         |       |   |        |        |
| persons   |           |   |         |       |   |        |        |
| from the  |           |   |         |       |   |        |        |
| community |           |   |         |       |   |        |        |
| to meet   |           |   |         |       |   |        |        |
| them.     |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| **QUALI   |           |   |         |       |   |        |        |
| FICATIONS |           |   |         |       |   |        |        |
| RE        |           |   |         |       |   |        |        |
| QUIRED:** |           |   |         |       |   |        |        |
| (1)       |           |   |         |       |   |        |        |
| Eccle     |           |   |         |       |   |        |        |
| siastical |           |   |         |       |   |        |        |
| en        |           |   |         |       |   |        |        |
| dorsement |           |   |         |       |   |        |        |
| by the    |           |   |         |       |   |        |        |
| official  |           |   |         |       |   |        |        |
| national  |           |   |         |       |   |        |        |
| endorsing |           |   |         |       |   |        |        |
| official  |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| faith     |           |   |         |       |   |        |        |
| group;    |           |   |         |       |   |        |        |
| (2) a     |           |   |         |       |   |        |        |
| Master of |           |   |         |       |   |        |        |
| Divinity  |           |   |         |       |   |        |        |
| degree or |           |   |         |       |   |        |        |
| e         |           |   |         |       |   |        |        |
| quivalent |           |   |         |       |   |        |        |
| graduate  |           |   |         |       |   |        |        |
| education |           |   |         |       |   |        |        |
| from an   |           |   |         |       |   |        |        |
| a         |           |   |         |       |   |        |        |
| ccredited |           |   |         |       |   |        |        |
| ins       |           |   |         |       |   |        |        |
| titution; |           |   |         |       |   |        |        |
| (3) 2     |           |   |         |       |   |        |        |
| units of  |           |   |         |       |   |        |        |
| Clinical  |           |   |         |       |   |        |        |
| Pastoral  |           |   |         |       |   |        |        |
| Education |           |   |         |       |   |        |        |
| (persons  |           |   |         |       |   |        |        |
| who have  |           |   |         |       |   |        |        |
| been      |           |   |         |       |   |        |        |
| con       |           |   |         |       |   |        |        |
| tinuously |           |   |         |       |   |        |        |
| employed  |           |   |         |       |   |        |        |
| as        |           |   |         |       |   |        |        |
| permanent |           |   |         |       |   |        |        |
| VA        |           |   |         |       |   |        |        |
| chaplains |           |   |         |       |   |        |        |
| since     |           |   |         |       |   |        |        |
| March 2,  |           |   |         |       |   |        |        |
| 1998 are  |           |   |         |       |   |        |        |
| exempt    |           |   |         |       |   |        |        |
| from this |           |   |         |       |   |        |        |
| req       |           |   |         |       |   |        |        |
| uirement) |           |   |         |       |   |        |        |
| (4) three |           |   |         |       |   |        |        |
| years     |           |   |         |       |   |        |        |
| pro       |           |   |         |       |   |        |        |
| fessional |           |   |         |       |   |        |        |
| ex        |           |   |         |       |   |        |        |
| perience, |           |   |         |       |   |        |        |
| at least  |           |   |         |       |   |        |        |
| one year  |           |   |         |       |   |        |        |
| of which  |           |   |         |       |   |        |        |
| was       |           |   |         |       |   |        |        |
| e         |           |   |         |       |   |        |        |
| quivalent |           |   |         |       |   |        |        |
| in        |           |   |         |       |   |        |        |
| c         |           |   |         |       |   |        |        |
| omplexity |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| respo     |           |   |         |       |   |        |        |
| nsibility |           |   |         |       |   |        |        |
| to the    |           |   |         |       |   |        |        |
| GS-11     |           |   |         |       |   |        |        |
| level,    |           |   |         |       |   |        |        |
| which has |           |   |         |       |   |        |        |
| dem       |           |   |         |       |   |        |        |
| onstrated |           |   |         |       |   |        |        |
| **all**   |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| f         |           |   |         |       |   |        |        |
| ollowing: |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| \(a\)     |           |   |         |       |   |        |        |
| ability   |           |   |         |       |   |        |        |
| to serve  |           |   |         |       |   |        |        |
| as a      |           |   |         |       |   |        |        |
| c         |           |   |         |       |   |        |        |
| onsultant |           |   |         |       |   |        |        |
| or expert |           |   |         |       |   |        |        |
| to a      |           |   |         |       |   |        |        |
| multidis  |           |   |         |       |   |        |        |
| ciplinary |           |   |         |       |   |        |        |
| treatment |           |   |         |       |   |        |        |
| team;     |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| \(b\)     |           |   |         |       |   |        |        |
| in-depth  |           |   |         |       |   |        |        |
| knowledge |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| related   |           |   |         |       |   |        |        |
| pro       |           |   |         |       |   |        |        |
| fessional |           |   |         |       |   |        |        |
| fields,   |           |   |         |       |   |        |        |
| par       |           |   |         |       |   |        |        |
| ticularly |           |   |         |       |   |        |        |
| in the    |           |   |         |       |   |        |        |
| b         |           |   |         |       |   |        |        |
| ehavioral |           |   |         |       |   |        |        |
| sciences; |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| (c) unde  |           |   |         |       |   |        |        |
| rstanding |           |   |         |       |   |        |        |
| of, and   |           |   |         |       |   |        |        |
| ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| respond   |           |   |         |       |   |        |        |
| to, the   |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| articular |           |   |         |       |   |        |        |
| concerns  |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| issues    |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| ertaining |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| treatment |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| veterans; |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| \(d\)     |           |   |         |       |   |        |        |
| knowledge |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| s         |           |   |         |       |   |        |        |
| tructure, |           |   |         |       |   |        |        |
| reg       |           |   |         |       |   |        |        |
| ulations, |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| ractices, |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| programs  |           |   |         |       |   |        |        |
| of health |           |   |         |       |   |        |        |
| care      |           |   |         |       |   |        |        |
| delivery  |           |   |         |       |   |        |        |
| systems;  |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| \(e\)     |           |   |         |       |   |        |        |
| Ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| interpret |           |   |         |       |   |        |        |
| and apply |           |   |         |       |   |        |        |
| a body of |           |   |         |       |   |        |        |
| rules,    |           |   |         |       |   |        |        |
| reg       |           |   |         |       |   |        |        |
| ulations, |           |   |         |       |   |        |        |
| policies, |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| rocedures |           |   |         |       |   |        |        |
| in        |           |   |         |       |   |        |        |
| pro       |           |   |         |       |   |        |        |
| fessional |           |   |         |       |   |        |        |
| practice; |           |   |         |       |   |        |        |
| (f)       |           |   |         |       |   |        |        |
| ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| develop   |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| maintain  |           |   |         |       |   |        |        |
| liaisons  |           |   |         |       |   |        |        |
| with a    |           |   |         |       |   |        |        |
| variety   |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| outside   |           |   |         |       |   |        |        |
| organ     |           |   |         |       |   |        |        |
| izations. |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| Time in   |           |   |         |       |   |        |        |
| Grade     |           |   |         |       |   |        |        |
| req       |           |   |         |       |   |        |        |
| uirement: |           |   |         |       |   |        |        |
| At least  |           |   |         |       |   |        |        |
| one year  |           |   |         |       |   |        |        |
| at GS-11. |           |   |         |       |   |        |        |
| A         |           |   |         |       |   |        |        |
| pplicants |           |   |         |       |   |        |        |
| must meet |           |   |         |       |   |        |        |
| all       |           |   |         |       |   |        |        |
| qual      |           |   |         |       |   |        |        |
| ification |           |   |         |       |   |        |        |
| req       |           |   |         |       |   |        |        |
| uirements |           |   |         |       |   |        |        |
| and time  |           |   |         |       |   |        |        |
| in grade  |           |   |         |       |   |        |        |
| re        |           |   |         |       |   |        |        |
| quirement |           |   |         |       |   |        |        |
| by (date) |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| **HOW TO  |           |   |         |       |   |        |        |
| APPLY**:  |           |   |         |       |   |        |        |
| Submit    |           |   |         |       |   |        |        |
| the       |           |   |         |       |   |        |        |
| following |           |   |         |       |   |        |        |
| forms to  |           |   |         |       |   |        |        |
| Human     |           |   |         |       |   |        |        |
| Resources |           |   |         |       |   |        |        |
| (l        |           |   |         |       |   |        |        |
| ocation), |           |   |         |       |   |        |        |
| to be     |           |   |         |       |   |        |        |
| received  |           |   |         |       |   |        |        |
| not later |           |   |         |       |   |        |        |
| than      |           |   |         |       |   |        |        |
| close of  |           |   |         |       |   |        |        |
| business  |           |   |         |       |   |        |        |
| on the    |           |   |         |       |   |        |        |
| closing   |           |   |         |       |   |        |        |
| date: VA  |           |   |         |       |   |        |        |
| form 4078 |           |   |         |       |   |        |        |
| "Ap       |           |   |         |       |   |        |        |
| plication |           |   |         |       |   |        |        |
| for       |           |   |         |       |   |        |        |
| Promotion |           |   |         |       |   |        |        |
| or        |           |   |         |       |   |        |        |
| Reass     |           |   |         |       |   |        |        |
| ignment;" |           |   |         |       |   |        |        |
| VA form   |           |   |         |       |   |        |        |
| 4676a     |           |   |         |       |   |        |        |
| "Sup      |           |   |         |       |   |        |        |
| plemental |           |   |         |       |   |        |        |
| Qual      |           |   |         |       |   |        |        |
| ification |           |   |         |       |   |        |        |
| St        |           |   |         |       |   |        |        |
| atement;" |           |   |         |       |   |        |        |
| and VA    |           |   |         |       |   |        |        |
| form      |           |   |         |       |   |        |        |
| 4667b     |           |   |         |       |   |        |        |
| "Su       |           |   |         |       |   |        |        |
| pervisory |           |   |         |       |   |        |        |
| Ap        |           |   |         |       |   |        |        |
| praisal." |           |   |         |       |   |        |        |
| Employees |           |   |         |       |   |        |        |
| outside   |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| Vetsburg  |           |   |         |       |   |        |        |
| VA        |           |   |         |       |   |        |        |
| Medical   |           |   |         |       |   |        |        |
| Center    |           |   |         |       |   |        |        |
| must also |           |   |         |       |   |        |        |
| submit    |           |   |         |       |   |        |        |
| Optional  |           |   |         |       |   |        |        |
| Form 612  |           |   |         |       |   |        |        |
| "Optional |           |   |         |       |   |        |        |
| Ap        |           |   |         |       |   |        |        |
| plication |           |   |         |       |   |        |        |
| for       |           |   |         |       |   |        |        |
| Federal   |           |   |         |       |   |        |        |
| Emp       |           |   |         |       |   |        |        |
| loyment," |           |   |         |       |   |        |        |
| and a     |           |   |         |       |   |        |        |
| copy of   |           |   |         |       |   |        |        |
| their     |           |   |         |       |   |        |        |
| most      |           |   |         |       |   |        |        |
| recent    |           |   |         |       |   |        |        |
| SF-50,    |           |   |         |       |   |        |        |
| "Not      |           |   |         |       |   |        |        |
| ification |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| Personnel |           |   |         |       |   |        |        |
| Action."  |           |   |         |       |   |        |        |
| Blank     |           |   |         |       |   |        |        |
| forms may |           |   |         |       |   |        |        |
| be picked |           |   |         |       |   |        |        |
| up in the |           |   |         |       |   |        |        |
| Human     |           |   |         |       |   |        |        |
| Resources |           |   |         |       |   |        |        |
| office,   |           |   |         |       |   |        |        |
| building  |           |   |         |       |   |        |        |
| .         |           |   |         |       |   |        |        |
| Documents |           |   |         |       |   |        |        |
| received  |           |   |         |       |   |        |        |
| after the |           |   |         |       |   |        |        |
| closing   |           |   |         |       |   |        |        |
| date will |           |   |         |       |   |        |        |
| not be    |           |   |         |       |   |        |        |
| co        |           |   |         |       |   |        |        |
| nsidered. |           |   |         |       |   |        |        |
| Documents |           |   |         |       |   |        |        |
| mailed in |           |   |         |       |   |        |        |
| g         |           |   |         |       |   |        |        |
| overnment |           |   |         |       |   |        |        |
| pos       |           |   |         |       |   |        |        |
| tage-paid |           |   |         |       |   |        |        |
| envelopes |           |   |         |       |   |        |        |
| will not  |           |   |         |       |   |        |        |
| be        |           |   |         |       |   |        |        |
| co        |           |   |         |       |   |        |        |
| nsidered. |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| Qualified |           |   |         |       |   |        |        |
| a         |           |   |         |       |   |        |        |
| pplicants |           |   |         |       |   |        |        |
| will be   |           |   |         |       |   |        |        |
| evaluated |           |   |         |       |   |        |        |
| on their  |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| ossession |           |   |         |       |   |        |        |
| of the    |           |   |         |       |   |        |        |
| following |           |   |         |       |   |        |        |
| rating    |           |   |         |       |   |        |        |
| factors.  |           |   |         |       |   |        |        |
| These     |           |   |         |       |   |        |        |
| rating    |           |   |         |       |   |        |        |
| factors   |           |   |         |       |   |        |        |
| should be |           |   |         |       |   |        |        |
| addressed |           |   |         |       |   |        |        |
| on forms  |           |   |         |       |   |        |        |
| 4676a and |           |   |         |       |   |        |        |
| 4667b.    |           |   |         |       |   |        |        |
| **Failure |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| provide   |           |   |         |       |   |        |        |
| complete  |           |   |         |       |   |        |        |
| in        |           |   |         |       |   |        |        |
| formation |           |   |         |       |   |        |        |
| on form   |           |   |         |       |   |        |        |
| 4676a may |           |   |         |       |   |        |        |
| result in |           |   |         |       |   |        |        |
| your      |           |   |         |       |   |        |        |
| receiving |           |   |         |       |   |        |        |
| less      |           |   |         |       |   |        |        |
| credit in |           |   |         |       |   |        |        |
| the       |           |   |         |       |   |        |        |
| rating    |           |   |         |       |   |        |        |
| proc      |           |   |         |       |   |        |        |
| ess.** 1. |           |   |         |       |   |        |        |
| Ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| co        |           |   |         |       |   |        |        |
| mmunicate |           |   |         |       |   |        |        |
| orally    |           |   |         |       |   |        |        |
| and in    |           |   |         |       |   |        |        |
| writing.  |           |   |         |       |   |        |        |
| 2.        |           |   |         |       |   |        |        |
| Ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| provide   |           |   |         |       |   |        |        |
| clinical  |           |   |         |       |   |        |        |
| pastoral  |           |   |         |       |   |        |        |
| care and  |           |   |         |       |   |        |        |
| c         |           |   |         |       |   |        |        |
| ounseling |           |   |         |       |   |        |        |
| in a      |           |   |         |       |   |        |        |
| h         |           |   |         |       |   |        |        |
| ealthcare |           |   |         |       |   |        |        |
| setting.  |           |   |         |       |   |        |        |
| 3.        |           |   |         |       |   |        |        |
| Ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| provide   |           |   |         |       |   |        |        |
| ministry  |           |   |         |       |   |        |        |
| in a      |           |   |         |       |   |        |        |
| pl        |           |   |         |       |   |        |        |
| uralistic |           |   |         |       |   |        |        |
| setting;  |           |   |         |       |   |        |        |
| 4.        |           |   |         |       |   |        |        |
| Knowledge |           |   |         |       |   |        |        |
| of        |           |   |         |       |   |        |        |
| worship   |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| rinciples |           |   |         |       |   |        |        |
| and       |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| ractices; |           |   |         |       |   |        |        |
| 5.        |           |   |         |       |   |        |        |
| Ability   |           |   |         |       |   |        |        |
| to        |           |   |         |       |   |        |        |
| establish |           |   |         |       |   |        |        |
| rela      |           |   |         |       |   |        |        |
| tionships |           |   |         |       |   |        |        |
| and deal  |           |   |         |       |   |        |        |
| ef        |           |   |         |       |   |        |        |
| fectively |           |   |         |       |   |        |        |
| with      |           |   |         |       |   |        |        |
| others;   |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| For       |           |   |         |       |   |        |        |
| further   |           |   |         |       |   |        |        |
| in        |           |   |         |       |   |        |        |
| formation |           |   |         |       |   |        |        |
| on merit  |           |   |         |       |   |        |        |
| p         |           |   |         |       |   |        |        |
| romotion, |           |   |         |       |   |        |        |
| see       |           |   |         |       |   |        |        |
| Medical   |           |   |         |       |   |        |        |
| Center    |           |   |         |       |   |        |        |
| m         |           |   |         |       |   |        |        |
| emorandum |           |   |         |       |   |        |        |
| 000-00,   |           |   |         |       |   |        |        |
| dated     |           |   |         |       |   |        |        |
| July 4,   |           |   |         |       |   |        |        |
| 1776.     |           |   |         |       |   |        |        |
|           |           |   |         |       |   |        |        |
| S         |           |   |         |       |   |        |        |
| IGNATURE, |           |   |         |       |   |        |        |
| Human     |           |   |         |       |   |        |        |
| Resources |           |   |         |       |   |        |        |
| Manager   |           |   |         |       |   |        |        |
+-----------+-----------+---+---------+-------+---+--------+--------+

# SPIRITUAL AND PASTORAL CARE STATEMENT OF WORK

HEALTH CARE RESOURCES IN ACCORDANCE WITH PUBLIC LAW 104-262 AND 38 USC
8153 TO BE FURNISHED BY THE CONTRACTOR AT \[VAMC\].

# 

# [PURPOSE:]{.underline} The purpose of this contract is to have \[contractor name and address\] (contractor) furnish spiritual and pastoral care services to veteran patients of the \[VAMC name and address\] (VA). 

The official title of the contractor while performing work under this
contract is "Chaplain." In this contract the term "chaplain" refers to
the contractor.

# 

# [PRICE SCHEDULE AND SERVICES:]{.underline}

# [PRICE]{.underline}

## CONTRACT YEAR -- \[Date\] through \[Date\]

[Service]{.underline} [Est.Quantity]{.underline} [Unit]{.underline}
[Rate per Service]{.underline}

1\. (itemize individual services \_\_\_ Service \$\_\_\_\_\_\_\_\_\_

or categories of services

services from the attached

alphabetical DSS/Event

Capture Chaplain Product

List)

**Estimated Quantities** -- All quantities listed herein are estimated
annual quantities. The Government is not obligated to purchase any
specified amount of services under this contract, but will be obligated
to make payment for all services requested and received in the
quantities and of the quality requested. The Government does not
guarantee or imply that any fixed number of orders/referrals for
services will be placed under this contract.

At the discretion of VA, the chaplain may be required to enter
information about the services provided in electronic and/or paper
systems of records. When this is required, the rates shown above include
completion of such documentation. The chaplain will not retrieve, view,
alter, enter, delete, copy, or release information from any VA patient
medical records without specific authorization by VA. If authorized
access to VA medical records, the chaplain will protect the
confidentiality of such records in accordance with applicable state and
federal laws and recognized standards of professional practice. While
retrieving, entering, or viewing any medical records in a VA system of
records the chaplain is responsible for protecting the records from
alteration, loss, or unauthorized release.

#### DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

The contractor should thoroughly review the specifications and become
familiar with the areas of coverage in order to become fully aware of
the scope of requirements. Failure to understand the contract
requirements shall not relieve the contractor from performing in
accordance with the meaning and intent of the specifications. This
contract represents a firm, fixed-price contract. Costs not incorporated
into the contractor's price will NOT be reimbursed by the Government.

**[DEFINITIONS OF SERVICES]{.underline}**

See the attached DSS/Event Capture Chaplain Product List

**[REFERRAL AND AUTHORIZATION FOR SERVICES]{.underline}**

All visits and services provided by the chaplain must be authorized by
the contracting officer's technical representative or designee. Unless
otherwise specified, in this contract the term "VA" refers to the
contracting officer's technical representative or designee.

**[CONTRACTOR QUALIFICATIONS]{.underline}**

1\. The chaplain must meet the qualification requirements for Chaplain
GS-060-11 given in VHA Handbook 5338.3. The Director, Chaplain Service
at the VA National Chaplain Center will verify and certify that the
chaplain meets these requirements prior to any work being performed
under this contract.

2\. The chaplain will provide VA with the following documents **and**
any other information and/or documents requested by the Director,
Chaplain Service to be used to verify the qualifications of the
chaplain.

Documents required:

> 1\. Ecclesiastical endorsement by the official national endorsing
> agent of a VA-registered religious faith group, dated within the past
> 12 months

2\. An application or resume

3\. copies of transcripts or diplomas documenting qualifying

> education
>
> 4\. copies of certificates documenting completion of required Clinical
> Pastoral Education

**[CONTRACTOR RESPONSIBILITIES]{.underline}**

1\. The chaplain agrees to provide services on specific dates and times
requested by VA, and to be available to meet emergency needs during
periods of time scheduled by VA.

2\. When called by VA to meet emergency needs, the chaplain will respond
to the page or phone call within 15 minutes. When directed by VA to
report to the medical center for an emergency need the chaplain will
report to the medical center within 45 minutes.

3\. The chaplain will be guided by the VHA policies as set forth in
Manual M-2, part II. Any questions or disputes about interpretation of
these policies will be decided by the contracting officer's technical
representative.

4\. The chaplain agrees to adhere to *[The Covenant and Code of Ethics
for Veterans Affairs Chaplains]{.underline}*, which is attached to this
contract. Any questions or disputes about interpretation of the code of
ethics will be decided by the Director, Chaplain Service or designee at
the VA National Chaplain Center.

5\. Nothing in this contract is intended or should be construed as
suggesting or directing any policy, practice, or action that is contrary
to the doctrine or practice of any faith group. Nevertheless, the
mission of the Veterans Health Administration to care for veterans is
paramount, and VHA may restrict or prohibit any practice that it deems
detrimental to the health or safety of patients.

6\. The chaplain will ensure that every veteran who is assigned to
his/her care has opportunities for free exercise of religion and that
the veterans' free exercise of religion is not hindered or impeded by VA
staff, other patients, volunteers or visitors. The chaplain will provide
care to all assigned veterans regardless of the veterans' religious
faith or lack thereof. If the chaplain cannot meet specific religious
needs of veterans he/she will make every effort to locate religious
leader(s) in the community who can provide for the veterans' religious
needs. The chaplain will notify the contracting officer's technical
representative prior to inviting any community clergy onto the facility.

7\. The chaplain will be vigilant to protect all veterans from attempts,
whether intentional or not, to influence their religious beliefs or
practices. Such attempts include unasked-for discussions of religion by
other patients, staff, or visitors; unauthorized distribution of
religious literature.

8\. The chaplain will be sensitive to the needs of veteran's family and
loved ones for spiritual/pastoral care. The chaplain will counsel and/or
refer them to community resources according to need.

9\. The chaplain will be responsible for furnishing his/her own
appropriate clothing.

10\. The chaplain may arrange for the purchase of sacramental wine,
religious literature, and other necessary supplies from the general post
fund in accordance with procedures given by the representative of the
contracting officer.

11\. The chaplain will not solicit any offerings or donations from
patients or families. All offerings and donations from patients and
families will be turned in to the medical center in accordance with
instructions given by the representative of the contracting officer.

12\. The chaplain will attend an orientation to the medical center on
date(s) and time(s) determined by VA. The chaplain will not be
compensated for attending this orientation.

13\. The chaplain will complete the following mandatory training within
\_\_\_\_\_\_\_\_\_ (length of time) after the approval of this contract.
This training will be given on the VA grounds, however the chaplain will
not be compensated for attending the training. The training may also be
completed via computer-based courses (if available), or by submitting
documentation of completion of outside training that is deemed
equivalent by the representative of the contracting officer:

Infection Control/HIV/Blood Borne Pathogens

Automated Data Processing Information Security

Fire Safety

Hazardous Materials Communications Requirements (MSDS)

Violence in the Workplace

Sexual Harassment

Customer Service

14\. The chaplain will attend the first chaplain orientation course that
takes place after the date of approval of this contract at the VA
National Chaplain Center in Hampton, Virginia. This course is two weeks
in length. The contractor will be reimbursed by VA for allowable travel
costs to and from Hampton, and will be compensated in the amount of
\$\_\_\_\_\_\_. Lodging at the VA National Chaplain Center is free.
However, if for unforseen reasons that are acceptable to the contracting
officer's technical representative the chaplain must pay for lodging
during some or all of the training he or she will be reimbursed for the
actual cost of such lodging, not to exceed \$\_\_\_\_\_\_ per day.

**[CONTRACTING OFFICER'S TECHNICAL REPRESENTATIVE]{.underline}**

The contracting officer's technical representative is hereby designated
to represent the contracting officer in furnishing technical guidance
and advice to the contractor in performing work under this contract. The
foregoing is not to be construed as authorization to interpret or
furnish advice and information to the contractor relative to the
financial or legal aspects of the contract. Enforcement of these
segments is vested in and is the responsibility of the contracting
officer.

The contracting officer's technical representative is also responsible
for monitoring the quantity and quality of services provided under this
contract and for certifying that the services provided meet the contract
requirements prior to payment being made to the contractor.

### 

### 

### APPROVAL OF CONTRACTOR PERSONNEL

[]{.mark}

The \[VA Facility\] reserves the right to refuse employment under this
contract or require dismissal from contract work of any contractor
employee or subcontractor employee who, by reason of previous
unsatisfactory performance at the \[VA Facility\] or for any other
reasonable reason, is considered by the contracting officer to be
objectionable, as long as thirty (30) days written notification of
unsatisfactory performance has been provided to the contractor and the
problem has not been cured in the thirty (30) day period.

[]{.mark}

[]{.mark}

**[AUTOMATED DATA PROCESSING (ADP) SECURITY]{.underline}**

[]{.mark}

The \[VA Facility\] will provide the contract chaplain with the same
access to Veterans Health Information and Technology Architecture
(VISTA) as the \[VA Facility\] Professional Staff. All contractor's
chaplains accessing the VISTA system will be required to sign and abide
by all VA security policies, and applicable VA confidentiality statutes,
38 U.S.C. §5701, 38 U.S.C. 7332, and the Privacy Act, 5 U.S.C. §552a.
These policies may be viewed in the office of the Director, Chaplain
Service.

[]{.mark}

[]{.mark}

**[ARRANGEMENT FOR REPLACEMENT STAFF]{.underline}**

[]{.mark}

The contractor shall provide scheduled services throughout the contract
period. In the event of the absence of the contractor for any reason,
the contractor shall bear the responsibility of providing a replacement
to provide the scheduled services.

[]{.mark}

[]{.mark}

### ALTERNATE SOURCES

If routine services are disrupted for more than two (2) consecutive
scheduled service requests, the Government reserves the right to procure
such services from an alternate source, until routine services are
restored by the contractor. When the Government exercises its right to
procure these services from an alternate source, the contractor shall
reimburse the Government for all charges in excess of the amount that
would have normally been incurred by the contract. A copy of the other
source's service ticket of other verifiable documentation shall be used
as the basis for any reimbursement.

  -------- ------------------------- ------- ------- ------------------------------------
  CH073N   ADDICT DRG&ALC GRP-PC     40626   99499   Pastoral care intervention related
                                                     to multi-substance abuse (See CH021N
                                                     ALCOHOL ADDICTION-PC and CH030N DRUG
                                                     ADDICTION-PC), including religious,
                                                     spiritual and/or other psychosocial
                                                     factors as may be pertinent.
                                                     Services are provided in a group
                                                     setting.

  CH018N   ADDICT DRG&ALC IND-PC     25941   99499   Pastoral care intervention related
                                                     to multi-substance abuse (See CH021N
                                                     ALCOHOL ADDICTION-PC and CH030N DRUG
                                                     ADDICTION-PC), including religious,
                                                     spiritual and/or other psychosocial
                                                     factors as may be pertinent.
                                                     Services are provided in a
                                                     individualized setting.

  CH004N   ADMISSION--PC             25927   99499   Pastoral care interaction with a
                                                     newly admitted patient focusing on
                                                     establishing rapport and discerning
                                                     whether further pastoral care
                                                     intervention is needed or desired by
                                                     the patient. Verbal or written
                                                     introduction to Chaplain Service is
                                                     provided. Preliminary spiritual
                                                     assessment is done but not in a
                                                     complete or formal way.

  CH070N   ADVANCE DIRECT CONSULT-PC 40119   99499   Pastoral care intervention with
                                                     primary focus on providing a
                                                     consultation response to religious,
                                                     spiritual and related psychosocial
                                                     issues relative to advance
                                                     directives. This may involve meeting
                                                     with patients, families and staff,
                                                     and review of medical records. (See
                                                     CH032N ETHICS/HOSPITAL QA-PC and
                                                     CH066N PATIENT ED-ADVNCD DIR-PC).

  CH074N   AIDS/HIV CNSL FAM WPT-PC  40627   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     counseling with patient and family
                                                     relating to religious, spiritual
                                                     and/or other psychosocial issues
                                                     relative to AIDS/HIV.

  CH019N   AIDS/HIV CNSL FAM-PC      25942   99499   Pastoral care intervention with
                                                     primary focus on providing family
                                                     counseling without the patient
                                                     present relating to religious,
                                                     spiritual an/or other psychosocial
                                                     issues relative to AIDS/HIV.

  CH020N   AIDS/HIV CNSL IND-PC      25943   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling with patient
                                                     relating to religious, spiritual
                                                     and/or other psychosocial issues
                                                     relative to AIDS/HIV.

  CH021N   ALCOHOL ADDICTION-PC      25944   99499   Pastoral care intervention with
                                                     primary focus on alcohol addiction
                                                     has been identified as the sole
                                                     addicting factor (see CH073N ADDICT
                                                     DRG&ALC IND -- PC for
                                                     multi-substance abuse and CH030N --
                                                     DRUG ADICTION), including religious,
                                                     spiritual and/or other psychosocial
                                                     factors as may be pertinent.

  CH022N   ALIENAT CHURCH-PC         25945   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and related
                                                     psychosocial issues relative to
                                                     alienation which prohibits/inhibits
                                                     participation in organized religion.
                                                     The patient has indicated prior
                                                     active participation in church. (See
                                                     CH029N DENOMIN ALIENATION-PC)

  CH023N   ANGER-PC                  25946   99499   Pastoral care intervention with
                                                     primary focus on the patient's
                                                     feelings of anger or resentment; may
                                                     be initiated with a OFTEN/VERY OFTEN
                                                     response to the comparable Spiritual
                                                     Injury Scale.

  CH024N   ANXIETY REDUCTION-PC      25947   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and/or related
                                                     psychosocial issues relative to
                                                     anxiety.

  CH005N   B/NA ADMISSION -- PC      25928   99499   Pastoral care visit with a newly
                                                     admitted patient was attempted but
                                                     patient was not available (NA).
                                                     However, a brochure (B) introducing
                                                     Chaplain availability was left at
                                                     the bedside.

  CH083N   BEREAVEMENT -- PC         48440   99499   Pastoral care intervention with a
                                                     primary focus on facilitating and
                                                     interpreting the processes of
                                                     mourning any loss. This intervention
                                                     includes spiritual and/or religious
                                                     dimensions and can involve both
                                                     therapeutic and sacramental
                                                     elements.

  CH077N   BOUNDARY CONFUSION-PC     48434   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and/or other
                                                     psychosocial issues relative to
                                                     boundary confusion (e.g. --
                                                     confusion related to differentiation
                                                     of self from others).

  CH062N   COMMUNION-PC              40111   99499   Pastoral care intervention with the
                                                     primary focus on the administration
                                                     of the religious/sacramental act of
                                                     communion or the Eucharist.

  CH063N   COMPUTER SPIR ASS'MT-PC   40112   99499   Pastoral care intervention with the
                                                     primary focus on the use of a
                                                     computerized spiritual assessment
                                                     such as the Berg CAP program or
                                                     Ashville VAMC Level I/II/III CAP
                                                     assessment to determine spiritual
                                                     needs. A chaplain should interpret
                                                     the data but may or may not directly
                                                     administer the assessment to the
                                                     patient.

  CH027N   CONCEPT OF DEATH-PC       25950   99499   Pastoral care intervention with a
                                                     primary focus on the concept of
                                                     death, including religious,
                                                     philosophical, theological,
                                                     spiritual concerns of the patient,
                                                     and/or other psychosocial factors as
                                                     may be pertinent.

  CH028N   CONFLICT RESOLUTION-PC    25951   99499   Pastoral care intervention with
                                                     primary focus on the resolution of
                                                     conflict confronting the patient.

  CH015N   CONSULTS--PC              25929   99499   Pastoral care intervention initiated
                                                     by a consultation request from a
                                                     clinician of another discipline for
                                                     an inpatient regarding religious or
                                                     spiritual concerns and/or their
                                                     impact on the patients sense of
                                                     health and well-being..

  CH071N   CONSULTS,OP-PC            40624   99499   Pastoral care intervention initiated
                                                     by a consultation request from a
                                                     clinician of another discipline for
                                                     an outpatient regarding religious or
                                                     spiritual concerns and/or their
                                                     impact on the patients sense of
                                                     health and well-being..

  CH029N   DENOMIN ALIENATION-PC     25952   99499   Pastoral care intervention with
                                                     primary focus on the patient's
                                                     perceived alienation from his/her
                                                     faith of origin, including
                                                     exploration of reasons for
                                                     separation, impact on spiritual
                                                     formation and well-being, desires
                                                     for reconciliation, development of
                                                     alternative denominational
                                                     affiliations. (See CH022N ALIENAT
                                                     CHURCH-PC)

  CH061N   DESPAIR/HOPELESSNESS-PC   40110   99499   Pastoral care intervention with
                                                     primary focus on the patient's
                                                     feelings of despair or hopelessness;
                                                     may be initiated with a OFTEN/VERY
                                                     OFTEN response to the comparable
                                                     Spiritual Injury Scale.

  CH007N   DNR CONSULTATION-PC       25931   99499   Pastoral care intervention with
                                                     primary focus on patient concerns
                                                     related to establishing
                                                     resuscitation directions as part of
                                                     advance healthcare planning,
                                                     including religious, spiritual
                                                     and/or other psychosocial factors as
                                                     may be pertinent.

  CH030N   DRUG ADDICTION-PC         25953   99499   Significant pastoral care
                                                     intervention with primary focus on
                                                     drug addiction has been identified
                                                     as the sole addicting factor (see
                                                     ADDICT DRG&ALC IND -- PC for
                                                     multi-substance abuse -- PC and
                                                     CH021N ALCOHOL ADDICTION-PC),
                                                     including religious, spiritual
                                                     and/or other psychosocial factors as
                                                     may be pertinent.

  CH031N   DYING--PC                 25954   99499   Pastoral care intervention with
                                                     primary focus on religious and
                                                     spiritual issues surrounding dying;
                                                     may include discussion of medical
                                                     aspects of dying, philosophical or
                                                     theological concerns; may be
                                                     concurrent with sacramental
                                                     ministries.

  CH078N   END OF LIFE--PC           48435   99499   Pastoral care intervention with
                                                     primary focus on End of Life care
                                                     including (but is not limited to)
                                                     provision of opportunities to
                                                     discuss feelings associated with
                                                     impending end of life, provision of
                                                     care based on known wishes,
                                                     provision of information regarding
                                                     available community resources,
                                                     acknowledgment/encouragement of
                                                     individual preference for guidance
                                                     and care by compassionate providers
                                                     who foster respect and dignity in an
                                                     environment of the patient/family
                                                     preference, discussion of religious
                                                     and spiritual concerns.

  CH032N   ETHICS/HOSPITAL QA-PC     25955   99499   Participation in Ethics Case
                                                     Consultation or Hospital Quality
                                                     Assurance review of patient
                                                     treatment; may be with or without
                                                     the patient present; may include
                                                     both bedside and chart review to
                                                     obtain pertinent data. (See CH070N
                                                     ADVANCE DIRECT.CONSULT-PC and CH066N
                                                     PATIENT ED-ADVNCD DIR-PC).

  CH033N   ETHNIC COMM ALIENATN-PC   25956   99499   Pastoral care intervention with
                                                     primary focus on the a patient's
                                                     alienation from his/her ethnic
                                                     community, including religious,
                                                     spiritual and/or other pertinent
                                                     psychosocial factors.

  CH075N   FAM. COUNSEL W/O PT--PC   40628   99499   Pastoral care intervention with
                                                     primary focus on providing family
                                                     counseling (including marital)
                                                     without the patient present.

  CH060N   FAMILY COUNSEL--PC        25957   99499   Pastoral care intervention with
                                                     primary focus on providing family
                                                     counseling (including marital) with
                                                     the patient present.

  CH034N   FEAR--PC                  25958   99499   Pastoral care intervention with
                                                     primary focus on the religious and
                                                     spiritual impact of fear on the
                                                     patient's sense of health and
                                                     wellbeing; may be initiated by OFTEN
                                                     or VERY OFTEN responses to the
                                                     Spiritual Injury scale.

  CH064N   FIFTH STEP--PC            40113   99499   Significant pastoral care
                                                     intervention with primary focus on
                                                     AA (or other 12 Step Programs) Fifth
                                                     Step work, may include instruction
                                                     on step work; may be concurrent with
                                                     other sacramental ministries (e.g.
                                                     -- Confession); usually a part of
                                                     Substance Abuse Treatment or
                                                     Aftercare.

  CH035N   FINANCIAL-PC              25959   99499   Pastoral care intervention with a
                                                     focus on any moral/religious aspects
                                                     of a patient\'s use of finances and
                                                     possible grief/loss issues. Some
                                                     occasions will call for some
                                                     introductory discussion of budgeting
                                                     principles. Often involves proper
                                                     referral to, or consultation with,
                                                     financial counselors, social workers
                                                     and case managers.

  CH008N   FOLLOW UP DNR-PC          25933   99499   Pastoral care intervention involving
                                                     guilt or grief work with both staff
                                                     and family members, and even other
                                                     patients as appropriate. Activities
                                                     may include prayer, scripture,
                                                     counseling, and referrals to other
                                                     providers.

  CH036N   FORGIVENESS--PC           25960   99499   Pastoral care intervention with
                                                     primary focus of interventions on
                                                     one or several of the following as
                                                     appropriate: understanding
                                                     forgiveness within one\'s own unique
                                                     context, hope of God\'s forgiveness,
                                                     process of accepting or offering
                                                     forgiveness, forgiveness of self,
                                                     employment of one\'s belief
                                                     structure to facilitate
                                                     healing/hope, AA Sixth and Seventh
                                                     Step work, planning and conducting
                                                     personalized rituals, prayer, and
                                                     discussion of appropriate
                                                     scriptures. May be concurrent with
                                                     specific sacramental ministries
                                                     (Communion, burning sage,
                                                     confession, etc.)

  CH065N   FUNERAL--PC               40114   99499   Pastoral care intervention with the
                                                     primary focus on conducting
                                                     religious service(s), sacraments,
                                                     and/or rituals that assist attendees
                                                     in honoring the deceased,
                                                     recognizing the reality of the loss,
                                                     and begin to view their grief within
                                                     the context of faith. Intervention
                                                     includes planning and conducting the
                                                     service(s), sacrament(s) or rituals,
                                                     or facilitating their occurrence to
                                                     meet specific religious preferences.

  CH037N   GAMBL ADDICT-PC           25961   99499   Pastoral Care intervention with a
                                                     primary focus on exploring the
                                                     spiritual dynamics of the patient\'s
                                                     gambling addiction and assisting the
                                                     patient to maximize spiritual
                                                     strengths to support continued
                                                     recovery. Includes referral to
                                                     resources for treatment, and
                                                     consultation with addiction
                                                     therapists.

  CH079N   GERIATRIC ISSUES-PC       48436   99499   Pastoral care intervention with a
                                                     patient over the age of 55. Possible
                                                     issues to address may include: worth
                                                     and meaning apart from youth,
                                                     physical health, and career; issues
                                                     around life after death;
                                                     opportunities for spiritual growth;
                                                     and God\'s unconditional love; and
                                                     family relationships. Pastoral
                                                     interventions are likely to include
                                                     the patient\'s family or significant
                                                     friends. Tools often useful are
                                                     prayer, scripture, individualized
                                                     rituals and sacramental rites.

  CH038N   GOD ALIENATION-PC         25962   99499   Pastoral care intervention to
                                                     address a patient\'s sense that God
                                                     has abandoned her/him, or the
                                                     patient\'s desire to become
                                                     connected (reconnected) to the
                                                     supreme being of their choice. As
                                                     appropriate to the religious
                                                     preference and current spiritual
                                                     maturity of the individual patient,
                                                     interventions may include assisting
                                                     the patient in examining current
                                                     beliefs, questions, needs, barriers,
                                                     experiences, and values as well as a
                                                     ministry of presence, reassurance,
                                                     sacramental ministry, scripture, and
                                                     prayer.

  CH039N   GRIEF--PC                 25963   99499   Pastoral care intervention with
                                                     primary focus on encouraging some
                                                     sense of hope, and managing sorrow
                                                     or mental distress caused by loss
                                                     (eg: of a loved one, job, health,
                                                     relationship, financial security,
                                                     self-esteem, bodily or mental
                                                     functioning, etc.). Incorporating
                                                     religious beliefs and spiritual
                                                     activities to manage or resolve
                                                     grief. May involve the patient\'s
                                                     friends, family or medical staff.
                                                     May be concurrent with other
                                                     interventions (see CH065N
                                                     FUNERAL-PC, CH040N HLTH
                                                     PROMOTION/WELLNESS-PC, CH084N POST
                                                     DEATH FAM CNSL-PC, CH010N POST
                                                     OPERATOVE VISIT-PC, CH027N CONCEPT
                                                     OF DEATH-PC, CH031N DYING-PC, CH009N
                                                     OTHER SACRAMENTS/RITES-PC), or other
                                                     pastoral care interventions.

  CH067N   GROUP SPIRITUALITY ED--PC 40116   99499   Pastoral care intervention with
                                                     primary focus on conducting or
                                                     facilitating classes to assist
                                                     groupings of patients in examining
                                                     belief systems, spiritual
                                                     self-evaluation, promoting spiritual
                                                     health, developing helpful spiritual
                                                     practices, and connecting with
                                                     appropriate religious communities.
                                                     This is most appropriately
                                                     accomplished in a rehabilitation
                                                     setting, with longer term patients,
                                                     or with closely followed
                                                     outpatients. (Bible studies are more
                                                     correctly recorded under CH025N
                                                     SCRIPTURE & THEOLOGY-PC).

  CH040N   GUILT--PC                 25964   99499   Pastoral care intervention with
                                                     primary focus on assisting the
                                                     patient to understand the impact of
                                                     a feeling of separation from one\'s
                                                     own values/morals on his/her ability
                                                     to function, to sort out real from
                                                     exaggerated guilt, to grasp the
                                                     significance of guilt within her/his
                                                     unique faith context and to consider
                                                     the rites and doctrine within
                                                     his/her faith that may aid in the
                                                     resolution of guilt. May be
                                                     concurrent with other interventions
                                                     (CH036N FORGIVENESS-PC, CH009N OTHER
                                                     SACRAMENTS/RITES-PC \[particularly
                                                     confession/ absolution\], and/or
                                                     12-Step work).

  CH041N   HLTH                      25965   99499   Pastoral care intervention with
           PROMOTION/WELLNESS--PC                    primary focus on encouraging the
                                                     patient to incorporate healthy
                                                     spiritual/religious activities to
                                                     promote wholeness and balance, as
                                                     well as adopting healthy patterns of
                                                     behavior and exploring
                                                     morally/religiously acceptable
                                                     options for medical compliance. (May
                                                     be concurrent with CH041N HLTH
                                                     PROMOTION/WELLNESS-PC).

  CH076N   HOME VISITS--PC           41043   99499   Pastoral care interventions
                                                     involving visits within the
                                                     patient's home (e.g. -- family
                                                     residence, residential care home,
                                                     contract nursing home). This is
                                                     usually done in support of
                                                     outpatient services such as Home
                                                     Based Primary Care and Hospice.

  CH042N   INSIGHT PROMOTION-PC      25966   99499   Pastoral Care intervention with
                                                     primary focus on incorporating the
                                                     patient\'s value system, morals, and
                                                     religious beliefs in the
                                                     interpretation of the realities of
                                                     her/his physical/mental health in
                                                     order to assist the patient in
                                                     forming a sound basis for making
                                                     decisions about self-care,
                                                     medication compliance, and future
                                                     medical treatment or mental health
                                                     care. Best accomplished in
                                                     conjunction with the planning of and
                                                     consultation with the healthcare
                                                     team. (May be concurrent with CH041N
                                                     HLTH PROMOTION/WELLNESS-PC and/or
                                                     CH044N MED PLAN COOP-PC).

  CH043N   MEANS TEST--PC            25967   99499   Pastoral Care intervention with
                                                     primary focus on a preliminary
                                                     assessment of a person\'s
                                                     eligibility for care, and a proper
                                                     referral to the enrollment office
                                                     for determination of the level of
                                                     eligibility of benefits. This most
                                                     often occurs when a non-enrolled
                                                     veteran without an appointment
                                                     requests pastoral care.

  CH044N   MED PLAN COOP--PC         25968   99499   Pastoral care intervention of with
                                                     primary focus on encouraging
                                                     compliance with planned treatment in
                                                     cooperation with a member(s) of the
                                                     healthcare team. Most successful in
                                                     consultation and consensus with
                                                     other clinicians on the team. The
                                                     patient may or may not be present.

  CH080N   MENTAL HEALTH--PC         48437   99499   Pastoral care intervention with
                                                     primary focus on spiritual/religious
                                                     beliefs/practices as they relate to
                                                     psychiatric diagnoses or conditions,
                                                     and the use of rituals, sacraments,
                                                     prayer, scripture and/or meditation
                                                     in supporting improved mental
                                                     stability and health. Best
                                                     accomplished in consultation with
                                                     the patient\'s mental health
                                                     providers. The patient may or may
                                                     not be present.

  CH045N   ONCO COUNSEL-PC           25969   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and/or related
                                                     psychosocial issues relative to
                                                     oncology and cancer related
                                                     diagnoses.

  CH001N   OTHER DIAG ASS'MT-PC      25924   99499   Pastoral care assessment with a
                                                     patient during which time the
                                                     caregiver attempts to determine
                                                     special needs of the patient through
                                                     the use of a specialized assessment
                                                     tool (e.g. -- Grief Severity
                                                     Assessment). (See CH063N COMPUTER
                                                     SPIR ASS'MT-PC, CH003N
                                                     SEMI-STRUCURED INTERVIEW-PC and
                                                     CH002N SPA SPIRITUAL ASSESSMENT-PC)

  CH009N   OTHER SACRAMENTS/RITES-PC 25934   99499   Pastoral care intervention during
                                                     which time a sacrament or rite other
                                                     than Sacrament of the Sick or
                                                     Communion was provided to the
                                                     patient. (e.g. baptism, confession,
                                                     absolution, marriage, etc.)

  CH046N   OTHER VISITS-PC           25970   99499   Pastoral care intervention with the
                                                     patient in which no single issue
                                                     dominated the visit.

  CH066N   PATIENT ED-ADVNCD DIR-PC  40115   99499   Pastoral care intervention with
                                                     primary focus on providing Patient
                                                     and family education on advance
                                                     health care planning. (See CH032N
                                                     ETHICS/HOSPITAL QA-PC and CH066N
                                                     PATIENT ED-ADVNCD DIR-PC).

  CH084N   POST DEATH FAM-CNSL--PC   48441   99499   Pastoral care intervention of with a
                                                     primary focus on intervention
                                                     following death with family and/or
                                                     significant others of the deceased.
                                                     The intervention may include
                                                     elements of both spiritual/religious
                                                     counseling and sacrament/liturgy.

  CH010N   POST OPERATIVE VISIT--PC  25935   99499   Pastoral care intervention with a
                                                     patient soon after surgery or other
                                                     medical treatment, with focus on
                                                     learning the results of the
                                                     surgery/treatment and providing
                                                     spiritual interaction designed to
                                                     enhance healing and holistic
                                                     recovery.

  CH011N   PRAYER REQUEST-PC         25936   99499   Pastoral care intervention with the
                                                     patient in which prayer was the
                                                     primary purpose of the visit.

  CH012N   PRE OPERATIVE VISIT-PC    25937   99499   Pastoral care intervention with the
                                                     patient in which pre-operative
                                                     concerns were addressed. (See also
                                                     CH024N ANXIETY REDUCTION-PC).

  CH047N   PSYCHOSIS REDUCT-PC       25971   99499   Pastoral care interaction with
                                                     patient during which time the
                                                     caregiver takes care to reinforce
                                                     present reality. Caregiver may
                                                     describe the date, time and place,
                                                     describing the patient's situation,
                                                     identifying the caregiver and the
                                                     patient. Observations or such
                                                     phenomena as the current weather or
                                                     season may be included. This may be
                                                     done in cooperation with other
                                                     members of the clinical team. This
                                                     intervention may include elements of
                                                     both spiritual/religious counseling
                                                     and sacrament/liturgy. This
                                                     intervention is employed primarily
                                                     with the intent of improving reality
                                                     orientation for patients with
                                                     psychosis.

  CH081N   PTSD-PC                   48438   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and related
                                                     psychosocial issues relative to Post
                                                     Traumatic Stress Disorder (PTSD).
                                                     This may be initiated by referral or
                                                     consult to the chaplain of a patient
                                                     diagnosed with PTSD or identified by
                                                     the chaplain as a possible issue for
                                                     treatment.

  CH048N   PURPOSE & MEANING-PC      25972   99499   Pastoral care interaction with
                                                     patient during which time the
                                                     caregiver attempts to facilitate the
                                                     patient's discernment of a sense of
                                                     purpose and meaning in his/her life.
                                                     Caregiver may draw upon spiritual
                                                     assessment tools in this process.
                                                     Caregiver may seek to review a
                                                     patient's spiritual history as an
                                                     aid to this discernment. This
                                                     intervention may include elements of
                                                     both spiritual/religious counseling
                                                     and sacrament/liturgy.

  CH049N   RADIO/TV UTILIZATION-PC   25973   99499   Pastoral care interaction with
                                                     patient and/or family members during
                                                     which time the caregiver may provide
                                                     or make use of broadcast material to
                                                     address spiritual needs or issues.
                                                     Broadcast may also be a means of
                                                     addressing worship/meditation needs
                                                     of patients and families, especially
                                                     when patient or family mobility is
                                                     an issue. Broadcast may additionally
                                                     be used for patient education.

  CH050N   REALITY ORIENTATION-PC    25974   99499   Pastoral care interaction with
                                                     patient during which time the
                                                     caregiver takes care to reinforce
                                                     present reality. Caregiver may
                                                     describe the date, time and place,
                                                     describing the patient's situation,
                                                     identifying the caregiver and the
                                                     patient. Observations or such
                                                     phenomena as the current weather or
                                                     season may be included. This may be
                                                     done in cooperation with other
                                                     members of the clinical team. This
                                                     intervention may include elements of
                                                     both spiritual/religious counseling
                                                     and sacrament/liturgy. This
                                                     intervention is employed primarily
                                                     with the intent of improving reality
                                                     orientation for dementia patients.

  CH051N   RENAL DIAL FAM CNSL-PC    25975   99499   Pastoral care interaction with
                                                     family members that elicits their
                                                     concerns, validates their feelings
                                                     and focuses on the implications of
                                                     the dialysis for the family as well
                                                     as the patient. Assessment of family
                                                     coping may occur. This may be done
                                                     in cooperation with other members of
                                                     the clinical team. This intervention
                                                     may make use of both spiritual
                                                     religious counseling and
                                                     sacrament/liturgy.

  CH013N   SACRAMENT OF THE SICK-PC  25938   99499   Pastoral care intervention with the
                                                     patient in which sacrament of the
                                                     sick was provided. (See CH009N OTHER
                                                     SACRAMENTS/RITES-PC).

  CH025N   SCRIPTURE & THEOLOGY-PC   25948   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and related
                                                     psychosocial issues relative to the
                                                     patient's understanding of scripture
                                                     and theology. The intervention may
                                                     include Bible study, catechism
                                                     instruction and other religious
                                                     instruction.

  CH003N   SEMI-STRUCTURED           25926   99499   Pastoral care interaction with a
           INTERVIEW--PC                             patient during which time the
                                                     caregiver attempts to assess/discern
                                                     the spiritual care intervention that
                                                     may be needed by the patient. The
                                                     caregiver uses relevant
                                                     ideas/questions from other formal
                                                     assessment tools combined with
                                                     his/her own
                                                     ideas/questions/techniques to obtain
                                                     needed information. (CH003N
                                                     SEMI-STRUCTURED INTERVIE-PC is also
                                                     used to record the procedure formal
                                                     interview technique developed by Dr.
                                                     McSherry).

  CH052N   SEXUAL ADDICTION-PC       25976   99499   Pastoral care interaction with
                                                     patient during which time the
                                                     caregiver provides feedback to the
                                                     patient that acknowledges the
                                                     reality of this form of compulsive
                                                     behavior. The caregiver is
                                                     non-judgmental and, at the same
                                                     time, careful to acknowledge the
                                                     destructive consequences of the
                                                     behavior. The caregiver may refer or
                                                     encourage the patient's
                                                     participation in a 12 Step group for
                                                     sex addicts. The caregiver will work
                                                     in cooperation with other members of
                                                     the clinical team, but will be
                                                     sensitive to the appropriateness of
                                                     any disclosure related to this
                                                     addiction. The intervention may
                                                     include elements of both
                                                     spiritual/religious counseling and
                                                     sacrament/liturgy.

  CH068N   SEXUALITY-PC              40117   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual counseling relating to
                                                     religious, spiritual and related
                                                     psychosocial issues relative to
                                                     sexuality and sexual identity.

  CH006N   SI/CRITICAL CARE--PC      25930   99499   Pastoral care intervention with a
                                                     seriously/critically ill patient
                                                     with primary focus on discerning and
                                                     providing spiritually uplifting
                                                     ministry which would complement the
                                                     holistic care being provided by
                                                     other members of the clinical team.

  CH053N   SIGNIFICANT OTHER-PC      25977   99499   Pastoral care intervention a person
                                                     in a significant relationship with
                                                     patient. Caregivers will need to
                                                     address the nature of that
                                                     relationship and will be sensitive
                                                     to issues of confidentiality before
                                                     proceeding with in depth contact.
                                                     Caregiver will be supportive, will
                                                     attempt to discern needs, issues and
                                                     implications for the significant
                                                     other. The caregiver will also give
                                                     attention to the spiritual/religious
                                                     resources of the significant other.
                                                     This intervention may include
                                                     elements of both spiritual/religious
                                                     counseling and sacrament/liturgy.

  CH054N   SOCIAL SKILL ENHANCMT--PC 25978   99499   Pastoral care intervention with
                                                     patient, during which time, the
                                                     caregiver will seek to model
                                                     appropriate social skills. The
                                                     caregiver may occasionally need to
                                                     be directive with the patient
                                                     regarding the appropriateness of
                                                     some behaviors. The caregiver will
                                                     work in cooperation with other
                                                     members of he clinical team.

  CH002N   SPA SPIRITUAL             25925   99499   Pastoral care intervention with a
           ASSESSMENT--PC                            patient during which time the
                                                     caregiver attempts to assess/discern
                                                     the primary spiritual care
                                                     intervention needed by the patient.
                                                     The caregiver uses the "Spiritual
                                                     Profile Assessment" tool created by
                                                     Dr. Elizabeth McSherry. This
                                                     intervention may also apply to any
                                                     templated profile assessment, such
                                                     as Mini-spiritual Assessment,
                                                     End-of-Life Spiritual Assessment, or
                                                     any objective, score-based
                                                     assessment.

  CH069N   SPIRITUAL ASSESSMENT--PC  40118   99499   Pastoral care intervention using an
                                                     assessment tool **other than** can
                                                     objective based assessment tool
                                                     similar to those developed by Berg
                                                     or McSherry. This code may be also
                                                     used to record the time related to
                                                     creating appropriate documentation
                                                     in the medical record.

  CH082N   SPIRITUAL DISTRESS--PC    48439   99499   Pastoral care intervention with a
                                                     primary focus on the issues and
                                                     concerns generating distress and/or
                                                     anxiety in the spiritual/religious
                                                     dimension. This intervention may
                                                     consist of theological constructs as
                                                     well as sacramental/liturgical care.

  CH055N   SPIRITUAL GROWTH-PC       25979   99499   Pastoral care intervention with
                                                     primary focus on providing
                                                     individual instruction or counseling
                                                     relating to spiritual growth.

  CH017N   STAFF COUNSELING-PC       25939   99499   Pastoral care of staff intervention
                                                     regarding religious, spiritual or
                                                     other psychosocial issues.
                                                     Intervention may be in conjunction
                                                     with Employee Assistance Program
                                                     referral to or from the chaplain.

  CH056N   STALMT SPIRITUAL GROWTH-  25980   99499   Pastoral care intervention with
           PC                                        primary focus on the patient's
                                                     feeling of lack of spiritual
                                                     vitality or growth.

  CH057N   SUICIDE--PC               25981   99499   Pastoral care intervention with
                                                     primary focus on patient's suicidal
                                                     thoughts, feelings or ideation.

  CH058N   THEODICY/UNFAIRNESS--PC   25982   99499   Pastoral care intervention with
                                                     primary focus on patient's struggle
                                                     with why God either
                                                     actively/passively ordains or
                                                     permits evil or suffering to happen
                                                     to the undeserving. May be initiated
                                                     with a OFTEN/VERY OFTEN response to
                                                     the corresponding question in the
                                                     Berg Spiritual Injury Scale.

  CH026N   UTILS CLSD CIRC-PC        25949   99499   Pastoral care intervention using
                                                     closed circuit broadcast
                                                     capabilities. Purpose of the
                                                     intervention may include worship and
                                                     patient education. Only one
                                                     intervention of [\<]{.underline} 10
                                                     minutes should normally be recorded
                                                     even though the worship service may
                                                     be longer. (See CH049N RADIO/TV
                                                     UTILIZATION-PC and CH059N VIS AIDS
                                                     UTILIZ-PC)

  CH059N   VIS AIDS UTILIZ-PC        25983   99499   Pastoral care intervention with the
                                                     utilization of visual aids as the
                                                     primary method to instruct or
                                                     provide counseling with the patient.

  CH014N   WORSHIP-PC                25940   99499   Patient participation in a service
                                                     of worship. Only one intervention of
                                                     [\<]{.underline} 10 minutes should
                                                     normally be recorded even though the
                                                     worship service may be longer.
  -------- ------------------------- ------- ------- ------------------------------------

**Categories/Clusters of Chaplain Products**

# 

# 

# #1 -- BASIC VISITATION

# 004 -- ADMISSION-PC

005 -- B/NA ADMISSION-PC

046 -- OTHER VISITS-PC

010 -- POST OPERATIVE VISIT-PC

012 -- PRE OPERATIVE VISIT-PC

# #2 -- RELIGIOUS MINISTRIES

006 -- COMMUNION-PC

065 -- FUNERAL-PC

036 -- FORGIVENESS-PC

009 -- OTHER SACRAMENTS/RITES-PC

011 -- PRAYER REQUEST-PC

013 -- SACRAMENT OF THE SICK-PC

006 -- SI/CRITICAL CARE-PC

014 -- WORSHIP-PC

# #3 - ASSESSMENT

063 -- COMPUTER SPIR ASS'MT-PC

001 -- OTHER DIAG ASS'MT-PC

003 -- SEMI-STRUCTURE INTERVIEW-PC

002 -- SPA SPIRITUAL ASSESSMENT-PC

069 -- SPIRITUAL ASSESSMENT-PC

####### #4 -- SPIRITUAL SUPPORT FOR CAREGIVER

075 -- FAM COUNSEL W/O PT-PC

060 -- FAMILY COUNSEL-PC

084 -- POST DEATH FAM CNSL-PC

051 -- RENAL DIAL FAM CNSL-PC

053 -- SIGNIFICANT OTHER-PC

017 -- STAFF COUNSELING-PC

# #5 -- MENTAL HEALTH

024 -- ANXIETY REDUCTION-PC

O77 -- BOUNDARY CONFUSION-PC

080 -- MENTAL HEALTH-PC

047 -- PSYCHOSIS REDUCT-PC

054 -- SOCIAL SKILL ENHANCMT-PC

082 -- SPIRITUAL DISTRESS-PC

# #6 -- CONSULT REQUESTS

070 -- ADVANCE DIRECT CONSULT-PC

051 -- CONSULTS-PC

071 -- CONSULTS,OP-PC

007 -- DNR CONSULTATION-PC

032 -- ETHICS/HOSPITAL QA-PC

# #7 -- PATIENT EDUCATION

022 -- ALIENAT CHURCH-PC

028 -- CONFLICT RESOLUTION-PC

029 -- DENOMIN ALIENATION-PC

033 -- ETHNIC COMM ALIENATN-PC

035 -- FINANCIAL-PC

079 -- GERIATRIC ISSUES-PC

067 -- GROUP SPIRITUALITY ED-PC

040 -- HLTH PROMOTION/WELLNESS-PC

042 -- INSIGHT PROMOTION-PC

044 -- MED PLAN COOP-PC

066 -- PATIENT ED-ADVNCD DIR-PC

049 -- RADIO/TV UTILIZATION-PC

025 -- SCRIPTURE & THEOLOGY-PC

068 -- SEXUALITY-PC

055 -- SPIRITUAL GROWTH-PC

056 -- STALMT SPIRITUAL GROWTH-PC

026 -- UTILS CLSD CIRC-PC

059 -- VIS AIDS UTILIZ-PC

# 

# 

# #8 -- SPECIAL PATIENT AREAS

073 -- ADDICT DRG&ALC GRP-PC

018 -- ADDICT DRG&ALC IND-PC

074 -- AIDS/HIV CNSL FAM WPT-PC

019 -- AIDS/HIV CNSL FAM-PC

020 -- AIDS/HIV CNSL IN-PC

021 -- ALCOHOL ADDICTION-PC

030 -- DRUG ADDICTION-PC

064 -- FIFTH STEP-PC

037 -- GAMBL ADDICT-PC

076 -- HOME VISIT-PC

043 -- MEANS TEST-PC

045 -- ONCO COUNSEL-PC

081 -- PTSD-PC

050 -- REALITY ORIENTATION-PC

052 -- SEXUAL ADDICTION-PC

057 -- SUICIDE-PC

# #9 -- DEATH & DYING

083 -- BEREAVEMENT-PC

031 -- DYING-PC

078 -- END OF LIFE-PC

008 -- FOLLOW UP DNR-PC

####### #10 -- SPIRITUAL INJURY

023 -- ANGER-PC

027 -- CONCEPT OF DEATH-PC

061 -- DESPAIR/HOPELESSNESS-PC

034 -- FEAR-PC

038 -- GOD ALIENATION-PC

039 -- GRIEF-PC

040 -- GUILT-PC

048 -- PURPOSE & MEANING-PC

058 -- THEODICY/UNFAIRNESS-PC

Standard Form 39

+------------+---+-------+-----+---+------------+------------+---------+
| # Req      |   |       | 1\. |   |            | 2\.        |         |
| uest For R |   |       | Sig |   |            | C          |         |
| eferral Of |   |       | nat |   |            | ertificate |         |
|  Eligibles |   |       | ure |   |            | No.        |         |
|            |   |       | of  |   |            |            |         |
|            |   |       | I   |   |            |            |         |
|            |   |       | ssu |   |            |            |         |
|            |   |       | ing |   |            |            |         |
|            |   |       | O   |   |            |            |         |
|            |   |       | ffi |   |            |            |         |
|            |   |       | cer |   |            |            |         |
|            |   |       | (   |   |            |            |         |
|            |   |       | OPM |   |            |            |         |
|            |   |       | Use |   |            |            |         |
|            |   |       | On  |   |            |            |         |
|            |   |       | ly) |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
|            |   |       |     |   |            | 3\.        | 4\.     |
|            |   |       |     |   |            | DEP/IPAP   | Date    |
|            |   |       |     |   |            | Clearance  | Issued  |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            | Yes        |         |
+------------+---+-------+-----+---+------------+------------+---------+
| I. AGENCY  |   |       |     |   |            |            |         |
| REQUEST    |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 5\.        |   |       | 7\. |   |            | 8.  Agency |         |
| Department |   |       | Bur |   |            |            |         |
| or Agency  |   |       | eau |   |            |    Request |         |
| Name       |   |       | or  |   |            |     Number |         |
|            |   |       | Fi  |   |            |            |         |
| Department |   |       | eld |   |            | 07-001     |         |
| of         |   |       | E   |   |            |            |         |
| Veterans   |   |       | sta |   |            |            |         |
| Affairs    |   |       | bli |   |            |            |         |
|            |   |       | shm |   |            |            |         |
|            |   |       | ent |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       | VA  |   |            |            |         |
|            |   |       | M   |   |            |            |         |
|            |   |       | edi |   |            |            |         |
|            |   |       | cal |   |            |            |         |
|            |   |       | Cen |   |            |            |         |
|            |   |       | ter |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       | Vet |   |            |            |         |
|            |   |       | sbu |   |            |            |         |
|            |   |       | rg, |   |            |            |         |
|            |   |       | Vi  |   |            |            |         |
|            |   |       | rgi |   |            |            |         |
|            |   |       | nia |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 6\.        |   |       |     |   |            | 9\. Date   |         |
| Department |   |       |     |   |            | of Request |         |
| or Agency  |   |       |     |   |            |            |         |
| Or         |   |       |     |   |            | January 3, |         |
| ganization |   |       |     |   |            | 1997       |         |
| Code       |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 10\.       |   |       |     |   |            | Submit     |         |
| Submit     |   |       |     |   |            | this       |         |
| Request    |   |       |     |   |            | request to |         |
| To: Board  |   |       |     |   |            | the        |         |
| of         |   |       |     |   |            | examining  |         |
| Excepted   |   |       |     |   |            | office,    |         |
| Service    |   |       |     |   |            | which has  |         |
| Examiners  |   |       |     |   |            | ju         |         |
| (301/111C) |   |       |     |   |            | risdiction |         |
|            |   |       |     |   |            | over the   |         |
| National   |   |       |     |   |            | work       |         |
| VA         |   |       |     |   |            | location   |         |
| Chaplain   |   |       |     |   |            | named in   |         |
| Center     |   |       |     |   |            | item 11,   |         |
|            |   |       |     |   |            | unless     |         |
| VA Medical |   |       |     |   |            | special    |         |
| Center     |   |       |     |   |            | prior      |         |
|            |   |       |     |   |            | agreement  |         |
| Hampton,   |   |       |     |   |            | has been   |         |
| VA 23667   |   |       |     |   |            | reached    |         |
|            |   |       |     |   |            | with the   |         |
|            |   |       |     |   |            | Office of  |         |
|            |   |       |     |   |            | Personnel  |         |
|            |   |       |     |   |            | M          |         |
|            |   |       |     |   |            | anagement. |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 11\.       |   |       |     |   |            | 12. Type   |         |
| Number of  |   |       |     |   |            |     of     |         |
| Vacancies, |   |       |     |   |            |     A      |         |
| Position   |   |       |     |   |            | ppointment |         |
| Title,     |   |       |     |   |            |            |         |
| Series     |   |       |     |   |            | Career or  |         |
| Code,      |   |       |     |   |            | Career-C   |         |
| Grade,     |   |       |     |   |            | onditional |         |
| *(Salary,  |   |       |     |   |            |            |         |
| If         |   |       |     |   |            | Temporary  |         |
| Ungraded)* |   |       |     |   |            | NTE        |         |
| Name of    |   |       |     |   |            |            |         |
| Duty       |   |       |     |   |            | (Provide   |         |
| Location   |   |       |     |   |            | jus        |         |
|            |   |       |     |   |            | tification |         |
| One        |   |       |     |   |            | in         |         |
| Chaplain   |   |       |     |   |            | Remarks)   |         |
| (specify   |   |       |     |   |            |            |         |
| major      |   |       |     |   |            | Term NTE 1 |         |
| faith      |   |       |     |   |            | year and 1 |         |
| group if   |   |       |     |   |            | day        |         |
| any)       |   |       |     |   |            |            |         |
| GS-0060-   |   |       |     |   |            | May be     |         |
| \_\_\_     |   |       |     |   |            | extended   |         |
|            |   |       |     |   |            | up to 4    |         |
| Vetsburg,  |   |       |     |   |            | years      |         |
| Virginia   |   |       |     |   |            |            |         |
|            |   |       |     |   |            | Excepted   |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 13\. Full  |   | 14\.  |     | 1 |            | 16\. Other |         |
| P          |   | Date  |     | 5 |            | Conditions |         |
| erformance |   | SF 52 |     | \ |            | of         |         |
| Level      |   | Init  |     | . |            | Employment |         |
|            |   | iated |     | R |            |            |         |
| G          |   |       |     | e |            | *(Shift,   |         |
| S-\_\_\_\_ |   |       |     | e |            | Seasonal,  |         |
|            |   |       |     | m |            | etc.)*     |         |
|            |   |       |     | p |            |            |         |
|            |   |       |     | l |            | employee   |         |
|            |   |       |     | o |            | must be    |         |
|            |   |       |     | y |            | willing to |         |
|            |   |       |     | m |            | perform    |         |
|            |   |       |     | e |            | call-back  |         |
|            |   |       |     | n |            | work       |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | P |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | y |            |            |         |
|            |   |       |     | L |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | s |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | C |            |            |         |
|            |   |       |     | l |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | a |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | d |            |            |         |
|            |   |       |     | ? |            |            |         |
|            |   |       |     | Y |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | s |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 17\.       |   |       |     | 1 |            |            |         |
| Indicate   |   |       |     | 8 |            |            |         |
| maximum    |   |       |     | \ |            |            |         |
| number of  |   |       |     | . |            |            |         |
| nights per |   |       |     | D |            |            |         |
| month the  |   |       |     | o |            |            |         |
| appointed  |   |       |     | e |            |            |         |
| person     |   |       |     | s |            |            |         |
| will be    |   |       |     | r |            |            |         |
| required   |   |       |     | e |            |            |         |
| to be away |   |       |     | q |            |            |         |
| from home  |   |       |     | u |            |            |         |
| in a       |   |       |     | e |            |            |         |
| travel     |   |       |     | s |            |            |         |
| status     |   |       |     | t |            |            |         |
|            |   |       |     | r |            |            |         |
| Not at all |   |       |     | e |            |            |         |
| 1 to 5 6   |   |       |     | l |            |            |         |
| to 10 11   |   |       |     | a |            |            |         |
| or more    |   |       |     | t |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | s |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | l |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | l |            |            |         |
|            |   |       |     | y |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | q |            |            |         |
|            |   |       |     | u |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | m |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | n |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | s |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | f |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | h |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | a |            |            |         |
|            |   |       |     | g |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | n |            |            |         |
|            |   |       |     | c |            |            |         |
|            |   |       |     | y |            |            |         |
|            |   |       |     | m |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | p |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | m |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | t |            |            |         |
|            |   |       |     | i |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | n |            |            |         |
|            |   |       |     | p |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | o |            |            |         |
|            |   |       |     | g |            |            |         |
|            |   |       |     | r |            |            |         |
|            |   |       |     | a |            |            |         |
|            |   |       |     | m |            |            |         |
|            |   |       |     | ? |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     | Y |            |            |         |
|            |   |       |     | e |            |            |         |
|            |   |       |     | s |            |            |         |
|            |   |       |     | N |            |            |         |
|            |   |       |     | o |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| 19\. Date  | 2 |       |     |   |            |            |         |
| Applicants | 0 |       |     |   |            |            |         |
| Available  | \ |       |     |   |            |            |         |
|            | . |       |     |   |            |            |         |
| I          | W |       |     |   |            |            |         |
| mmediately | o |       |     |   |            |            |         |
|            | r |       |     |   |            |            |         |
| By         | k |       |     |   |            |            |         |
| *(da       | S |       |     |   |            |            |         |
| te*):      | c |       |     |   |            |            |         |
|            | h |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            | d |       |     |   |            |            |         |
|            | u |       |     |   |            |            |         |
|            | l |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            | F |       |     |   |            |            |         |
|            | u |       |     |   |            |            |         |
|            | l |       |     |   |            |            |         |
|            | l |       |     |   |            |            |         |
|            | - |       |     |   |            |            |         |
|            | T |       |     |   |            |            |         |
|            | i |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            | E |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | p |       |     |   |            |            |         |
|            | l |       |     |   |            |            |         |
|            | o |       |     |   |            |            |         |
|            | y |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            | n |       |     |   |            |            |         |
|            | t |       |     |   |            |            |         |
|            | P |       |     |   |            |            |         |
|            | a |       |     |   |            |            |         |
|            | r |       |     |   |            |            |         |
|            | t |       |     |   |            |            |         |
|            | - |       |     |   |            |            |         |
|            | T |       |     |   |            |            |         |
|            | i |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            | E |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | p |       |     |   |            |            |         |
|            | l |       |     |   |            |            |         |
|            | o |       |     |   |            |            |         |
|            | y |       |     |   |            |            |         |
|            | m |       |     |   |            |            |         |
|            | e |       |     |   |            |            |         |
|            | n |       |     |   |            |            |         |
|            | t |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
|            | H |       |     |   |            |            |         |
|            | o |       |     |   |            |            |         |
|            | u |       |     |   |            |            |         |
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|            | : |       |     |   |            |            |         |
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+------------+---+-------+-----+---+------------+------------+---------+
| 21\.       |   |       |     |   |            |            |         |
| Remarks    |   |       |     |   |            |            |         |
| (Any       |   |       |     |   |            |            |         |
| qua        |   |       |     |   |            |            |         |
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| should be  |   |       |     |   |            |            |         |
| described  |   |       |     |   |            |            |         |
| on a SF    |   |       |     |   |            |            |         |
| 39A        |   |       |     |   |            |            |         |
| submitted  |   |       |     |   |            |            |         |
| with this  |   |       |     |   |            |            |         |
| request.   |   |       |     |   |            |            |         |
| Indicate   |   |       |     |   |            |            |         |
| submission |   |       |     |   |            |            |         |
| of a SF    |   |       |     |   |            |            |         |
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|            |   |       |     |   |            |            |         |
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+------------+---+-------+-----+---+------------+------------+---------+
| 22\.       |   |       |     |   | 23\. For   |            |         |
| Address    |   |       |     |   | Further    |            |         |
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| Sent:      |   |       |     |   | Telephone  |            |         |
|            |   |       |     |   | No.)       |            |         |
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|            |   |       |     |   | 55         |            |         |
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| Affairs    |   |       |     |   |            |            |         |
| Medical    |   |       |     |   |            |            |         |
| Center     |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
| 100        |   |       |     |   |            |            |         |
| Veterans   |   |       |     |   |            |            |         |
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|            |   |       |     |   |            |            |         |
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| VA XXXXX   |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
|            |   |       |     |   | 24\.       |            |         |
|            |   |       |     |   | Approved   |            |         |
|            |   |       |     |   | By (Name   |            |         |
|            |   |       |     |   | and Title) |            |         |
|            |   |       |     |   |            |            |         |
|            |   |       |     |   | Hubert H.  |            |         |
|            |   |       |     |   | Humphrey,  |            |         |
|            |   |       |     |   | Personnel  |            |         |
|            |   |       |     |   | Officer    |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| II\.       |   |       |     |   |            |            |         |
| CER        |   |       |     |   |            |            |         |
| TIFICATION |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| To         |   |       |     |   |            |            |         |
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| Office:    |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
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| attached   |   |       |     |   |            |            |         |
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| must be    |   |       |     |   |            |            |         |
| authorized |   |       |     |   |            |            |         |
| by the     |   |       |     |   |            |            |         |
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+------------+---+-------+-----+---+------------+------------+---------+
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+------------+---+-------+-----+---+------------+------------+---------+
| To Issuing |   |       |     |   |            |            |         |
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| Report on  |   |       |     |   |            |            |         |
| c          |   |       |     |   |            |            |         |
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| is         |   |       |     |   |            |            |         |
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| and        |   |       |     |   |            |            |         |
| original   |   |       |     |   |            |            |         |
| ap         |   |       |     |   |            |            |         |
| plications |   |       |     |   |            |            |         |
| (and       |   |       |     |   |            |            |         |
| at         |   |       |     |   |            |            |         |
| tachments) |   |       |     |   |            |            |         |
| of         |   |       |     |   |            |            |         |
| eligibles  |   |       |     |   |            |            |         |
| not        |   |       |     |   |            |            |         |
| selected   |   |       |     |   |            |            |         |
| for        |   |       |     |   |            |            |         |
| a          |   |       |     |   |            |            |         |
| ppointment |   |       |     |   |            |            |         |
| are        |   |       |     |   |            |            |         |
| returned.  |   |       |     |   |            |            |         |
|            |   |       |     |   |            |            |         |
| **We       |   |       |     |   |            |            |         |
| Desire     |   |       |     |   |            |            |         |
| Further    |   |       |     |   |            |            |         |
| Cer        |   |       |     |   |            |            |         |
| tification |   |       |     |   |            |            |         |
| For The    |   |       |     |   |            |            |         |
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| Number of  |   |       |     |   |            |            |         |
| Va         |   |       |     |   |            |            |         |
| cancies:** |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+
| Signature  |   |       |     |   |            | Date       |         |
| and Title  |   |       |     |   |            | Signed     |         |
| of         |   |       |     |   |            |            |         |
| Appointing |   |       |     |   |            |            |         |
| Officer    |   |       |     |   |            |            |         |
+------------+---+-------+-----+---+------------+------------+---------+

**Instructions For Submitting Requests To Certify That Individuals To Be
Used Under Contract Or On A Fee-Basis Meet Minimum Qualification
Requirements**

Each contract and fee-basis chaplain must be certified as meeting
minimum qualification requirements by the Board of Excepted Service
Examiners (BESE) prior to appointment or issuance of contract. (VHA
Handbook 1111.2, paragraph 16d)

We realize that time is often of the essence when acquiring contract or
fee-basis personnel. We pledge to make the certification process as
quick and simple as possible. In most cases we will make a decision on
an individual within one workday if all the necessary information is
provided.

The instructions for requesting BESE certification are as follows:

Certification can be requested by the Chief/Supervisory/Lead Chaplain,
or the Human Resources Staff or the Contracting Staff. The request may
be in any format, by letter, memo, or e-mail. The request must include
the name and phone number of the individual to whom the certification
will be sent.

The following documents must be submitted with the request:

1\. Ecclesiastical endorsement dated within the past year

2\. An application or resume (OF-612 may be used, but is not required)

3\. A copy of a diploma or graduate transcripts. If the individual does
not

> have a Master of Divinity degree, transcripts must be submitted so
> that
>
> we can make a determination as to M. Div. equivalency. We do not
>
> require official transcripts for this purpose. Student copies are
>
> acceptable.

4\. Completed form OF-306 \"Declaration for Federal Employment\"

5\. Copies of document(s) showing completion of 2 units of Clinical

Pastoral Education. Any of the following documents are acceptable:

-   Certificates of completion

-   A signed letter from the CPE Supervisor(s)

-   A CPE verification issued by the ACPE National Office

-   Copies of CPE supervisory appraisals

-   Transcripts that show 2 semesters of \"Clinical Pastoral
    Education.\"

> (other course titles, for example \"Clinical Pastoral Orientation\"
> are not automatically equivalent and must be accompanied by a
> narrative description of the course content)

NOTE: The requirement for CPE may be waived for individuals who perform
liturgical and sacramental ministry and who work not more than 416 hours
per year. If the medical center desires a waiver of the CPE requirement,
please so specify in the request for certification.

**Submit all documents to:**

**Department of Veterans Affairs**

**National VA Chaplain Center (301/111C)**

**100 Emancipation Drive, Building 33**

**Hampton, VA 23667**

# Attn: Contract/Fee Certification

Documents may be faxed to: 757-728-3179

**Common causes of delay:**

Our experience reviewing job applications has shown that the following
are the most frequent reasons for delay:

1\. The applicant submits application documents directly to the BESE
separately from the certification request. For purposes of
contract/fee-basis certification, medical center officials should submit
all documents to the BESE in one package.

2\. Insufficient information to determine whether the individual meets
the length of experience requirement. The individual must provide the
beginning and ending dates of [each]{.underline} job in ministry or
pastoral care; a description of the duties; [and the number of hours per
week]{.underline}. Part time experience is pro-rated according to its
proportion of a 40-hour workweek. Work need not have been compensated to
be creditable, but it must have been professional ministry.

3\. Insufficient information to determine whether an individual's
training is equivalent to CPE. The individual should provide a detailed
description of all of the following components when describing training
that he/she wishes to be considered toward CPE equivalency:

> The beginning and ending dates of the education
>
> The name and type of institution in which the supervised ministry was
> performed
>
> The name and title of the individual who provided the supervision
>
> The number of hours of supervised ministry performed
>
> The manner in which the ministry was evaluated (e.g. verbatims)
>
> A description of the didactic sessions on professional functioning and
> theological reflection
>
> A description of the interaction with a peer group during the learning
> experience
>
> A description of how personal, pastoral, and professional identity
> issues were addressed

*For further information, contact John J. Batten, Program Analyst at the
National VA Chaplain Center, at 757-728-7062*

[^1]: The exception is the Director, Chaplain Service, appointed under
    Title 38 7306