ADW Questionnaire for Hospital Chaplains - Archdiocese of Washington

Name*

First Last

Hospital/Facility you serve*

Parish or Address of Residence

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Cell Phone*

Preferred Email*

Are you considered a full or part time chaplain, or are you paid a stipend or as a PRN?

How many hours a week do you work at your facility?

Does your schedule include on-call and overnight coverage?

How many years have you been serving in healthcare ministry?

Are you an employee of the facility where you serve?

Is your ministry to your facility part of your pastoral responsibility to a parish?

What priest serves as a back up or replacement for you to have time away as needed?

Please list priest name and parish/community

Are you asked to provide bio-ethical consultation?

Do you sit on your facility’s bioethics committee?

Do you speak other languages than English?

Please list all languages

How would you best describe the facility at which you minister?

Do you have access to a patient’s medical record?

Can you enter information into the patient’s medical record?

Has your facility provided you with training regarding HIPAA?

Does your facility provide continuing education for your professional and spiritual development and growth?

Does your facility expect you to have certification from an accrediting body such as the National Association of Catholic Chaplain (NACC)?

Does your facility pay the appropriate NACC fees and dues?

What training or support would you like to receive from the Archdiocese of Washington?

What other information would you like the Archdiocese of Washington to know about your ministry to the sick?