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ISPEC 2021 Application Form

Thank you for your interest in the Interprofessional Spiritual Care Education Curriculum (ISPEC) Course scheduled for October 14 & 15th, 2021. At GWish, we envision a world where ALL patients and families have access to spiritual care during a health crisis. ISPEC is your opportunity to join the movement, leading the way to more compassionate health care systems for everyone.

Application Instructions

Please read the instructions provided throughout the application carefully and address all required information. Use the checklist provided to make sure that all required information is included in your application.

Note: The ISPEC program is designed to be taken as clinician-chaplain pairs, where health care providers partner with a chaplain or spiritual care provider to attend the training and develop goals to integrate spiritual care into their institution. Each organization’s team will ideally include one clinician and one chaplain. We recognize there are situations that do not allow for team participation. If you are unable to attend ISPEC as a clinician-chaplain pair but would like to apply as an individual, contact Dr. Puchalski at gwish@gwu.edu.

One application per team. Some sections of the application are to be completed as a team and other sections are designated for each individual team member to complete separately. Please coordinate with your team member to ensure all sections are completed. Incomplete applications will not be considered. You can save your application to complete at another time or to share between team members. Do not start multiple applications – use your return code (outlined below) to continue working on your original application.

As you complete the application, please keep in mind:

One applicant can complete the application for both team members or access to the application can be shared so each team member can provide his or her information. Have your team member’s email address available; you will use it to share access to the application.
When completing the institutional information section, please provide information about the organization at which you partner and will work together as a team to integrate the ISPEC training.
As part of the application, we ask that each clinician-chaplain pair submit three integration goals. Please develop and submit these goals jointly as a team. If you are applying without a team member, consider how you will collaborate with others at your institution on your integration goals.

To save your application to complete later DO NOT HIT SUBMIT:

Select “Save and Return Later” at the bottom of the application. You will be presented with a code – make a note of this code. A box will appear, and you will be asked to enter your email address. A link to the application will be sent to this email. To continue working on your application, click on the link and enter your return code.

To share access to the application with your team member DO NOT HIT SUBMIT:

When the first team member has input his or her information, select “Save and Return Later” at the bottom of the application. You will be presented with a code – make a note of this code. A box will appear, and you will be asked to enter an email address. Enter the address of the second team member. A link to the application will be sent to this email; you will also need to send the second team member the code in a separate email/text/etc. so they can access the application through the link. The second team member will scroll down to input his or her information in the section following information for the first team member. Questions for the second team member will have (2nd Team Member) beside them.

APPLICATION DEADLINE: All applications are due October 1, 2021. Acceptance notices will be sent out on a rolling basis. For questions regarding the ISPEC course or assistance in completing the application, please contact Cherron Gardner-Thomas at gwish@gwu.edu.

Thank you! We look forward to reviewing your application.

Application Checklist

General Applicant Information (One per Team Member)
Institutional Information (One per Team)
Three Goals (One per Team)
One Letter of Support from Supervisor/Administrator (One per Team)

Are you applying with a team member?

* must provide value

Yes

reset

What is today's date?

* must provide value

D-M-Y

Prefix

First Name

* must provide value

Middle Initial

Last Name

* must provide value

Suffix

Current Title/Position

* must provide value

Are you an international participant?

* must provide value

Yes

reset

Address

* must provide value

Address 2

City/Town

* must provide value

State/Province

* must provide value

Zip Code

Zip Code (International)

Country

* must provide value

Phone Number

* must provide value

Phone Number (International)

What is your profession? (Select all that apply)

* must provide value

Advanced Practice Nurse / Nurse Practitioner

Chaplain/Spiritual Care Provider

Counselor/Therapist

Nurse

Nursing Assistant

Occupational Therapist

Physical Therapist

Physician

Physician Assistant

Psychologist

Social Worker

Other

If other, please specify

I specialize in Pediatrics; my patient/client population ranges from birth to age 18.

* must provide value

Yes

reset

What is your degree? (Select all that apply)

* must provide value

RN/APN

DMin

DPhil

EdD

EdM

LCSW/MSW

MD/DO/MBBS

MDiv

MPH

PharmD

PhD

ThD

Other

If other, please specify

If you are faculty at an academic institution, what is your rank?

N/A - Not Faculty

Instructor

Assistant Professor

Associate Professor

Professor

Other

If other, please specify

Please indicate your gender(s).

Male

Female

Other

Prefer not to specify

Please indicate your ethnicity

Hispanic or Latino

Not Hispanic or Latino

Prefer not to specify

reset

Please indicate your race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Paciﬁc Islander

White

More than one race

Prefer not to specify

reset

FOR CLINICIANS: Have you had any previous training in Spiritual Care or Spirituality and Health?

Yes

reset

Please describe.

Expand

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

I am a spiritual person.

reset

I am a religious person.

reset

I am neither a spiritual nor a religious person.

reset

If you have a religious affiliation, please indicate it below. You may select all that apply.

N/A - No religious affiliation (e.g. Agnostic, Atheist, Other)

Baháʼí

Buddhist

Christian (Anglican, Catholic, Orthodox, or Protestant)

Folk Religion(s)

Hindu

Jewish

Muslim

Sikh

Universalist

Other

If other, please specify

Prefix (2nd Team Member)

First Name (2nd Team Member)

* must provide value

Middle Initial (2nd Team member)

Last Name (2nd Team member)

* must provide value

Suffix

Current Title/Position (2nd Team Member)

* must provide value

Are you an international participant? (2nd Team Member)

Yes

reset

Address (2nd Team Member)

* must provide value

Address 2 (2nd Team Member)

City/Town (2nd Team Member)

* must provide value

State/Province (2nd Team Member)

Zip Code (2nd Team Member)

Country (2nd Team Member)

* must provide value

E-mail (2nd Team Member)

* must provide value

Phone Number (2nd Team Member)

* must provide value

Phone Number (international) (2nd Team Member)

* must provide value

What is your profession? (2nd Team Member)

* must provide value

Advanced Practice Nurse / Nurse Practitioner

Chaplain/Spiritual Care Provider

Counselor/Therapist

Nurse

Nursing Assistant

Occupational Therapist

Physical Therapist

Physician

Physician Assistant

Psychologist

Social Worker

Other

If other, please specify (2nd Team Member)

I specialize in Pediatrics; my patient/client population ranges from birth to age 18. (2nd Team Member)

Yes

reset

What is your degree? (2nd Team Member)

* must provide value

RN/APN

DMin

DPhil

EdD

EdM

LCSW/MSW

MD/DO/MBBS

MDiv

MPH

PharmD

PhD

ThD

Other

If other, please specify (2nd Team Member)

If you are faculty at an academic institution, what is your rank? (2nd Team Member)

N/A - Not Faculty

Instructor

Assistant Professor

Associate Professor

Professor

Other

If other, please specify (2nd Team Member)

Please indicate your gender(s). (2nd Team Member)

Male

Female

Other

Prefer not to specify

Please indicate your ethnicity (2nd Team Member)

Hispanic or Latino

Not Hispanic or Latino

Prefer not to specify

reset

Please indicate your race (2nd Team Member)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Paciﬁc Islander

White

More than one race

Prefer not to specify

reset

FOR CLINICIANS: Have you had any previous training in Spiritual Care or Spirituality and Health? (2nd Team Member)

Yes

reset

Please describe

Expand

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

I am a spiritual person.

reset

I am a religious person.

reset

I am neither a spiritual nor a religious person.

reset

If you have a religious affiliation, please indicate it below. You may select all that apply. (2nd Team Member)

N/A - No religious affiliation (e.g. Agnostic, Atheist, Other)

Baháʼí

Buddhist

Christian (Anglican, Catholic, Orthodox, or Protestant)

Folk Religion(s)

Hindu

Jewish

Muslim

Sikh

Universalist

Other

If other, please specify

Employing Institute/Program

* must provide value

Address

* must provide value

Address 2

City/Town

* must provide value

State/Province

* must provide value

Zip Code

* must provide value

Zip Code (International)

Country

* must provide value

Phone Number

Work Setting (Select all that apply)

* must provide value

Assisted Living or Independent Living Center

Cancer Center

Long-term Care Setting or Nursing Home or Memory Unit

Home Care Setting

Hospice

Hospital

Outpatient Clinic

Other

If other, please specify

In general, for whom do you provide care?

* must provide value

Adults

Children

Both Adults and Children

reset

The purpose of this course is to educate clinician/chaplain pairs from the same health setting.

FOR CLINICIANS: Learn skills to integrate spiritual care into your clinical practice and teach concepts to others in the organization.

FOR CHAPLAINS: Create the opportunity to partner and teach with a clinician to achieve a broader, more systemic reach across the institution.

The program emphasizes leadership skills, institutional culture change, and team goal development. As a participant, you will be part of a one-year ISPEC© 2021 community. In this community, we will share stories and best practices as you implement your goals and gain experience teaching ISPEC© concepts to others in your organization.

Preparation for completing this objective begins with the development of SMART goals which are:

Specific (simple, sensible, significant)
Measurable (meaningful, motivating)
Achievable (agree, attainable)
Relevant (reasonable, realistic and resourced, results-based)
Time bound (time-based, time-limited, time/cost limited, timely, time-sensitive)

As part of the application, we ask that you submit three goals that will positively impact spiritual care at your institution. Please submit your goals (as a team) related to the institution where you typically work together and plan to integrate the ISPEC course concepts. During the course you will have time to discuss, refine—even change—your goals, but we encourage you to start thinking about them here.

Sample Goals:

Clinician/Chaplains: Train colleagues in doing a spiritual screening or history.
Clinician/Chaplains: Prepare and present an in-service on integrating spiritual assessment to one ICU unit nurse group
Clinician/Chaplains: Hold monthly meetings with ER/Trauma staff to support spiritual wellness and reduce spiritual distress of the nursing staff

Goal 1:

* must provide value

Expand

Goal 2:

* must provide value

Expand

Goal 3:

* must provide value

Expand

Letter of Support from the Institution's Administrator/Supervisor (Required)

The successful implementation of the curriculum will depend on support and commitment from your institution. Therefore, one letter of support per team must be included in your application. An administrator/supervisor from your institution must provide one letter on company letterhead indicating his or her support and commitment to your attendance at the ISPEC Course and efforts to extend spiritual care skills training in your clinical setting.

Supervisor Name:
Supervisor Email:

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