Interprofessional Spiritual Care Education Curriculum

Thank you for your interest in applying for the Interprofessional Spiritual Care Education Curriculum (ISPEC) Program. Please read the instructions provided throughout the application form carefully and provide all required information. This application is formatted to allow you to type directly onto the online form. You could upload your letter of support at the end of application. For all questions regarding the application, please contact the program coordinator, Melanie Atwell, 202-994-3549 or via email at: matwell08@gwu.edu.

ISPEC Online Application

I. General Applicant Information - Applicant #1 (Clinician)

Contact Information

* Name
* Current Title/Position
Home Address
City/Town
State/Province
ZIP/Postal Code
Country
* Email Address
Phone Number
* Degree/Credentials
* Specialty
Critical Care
Family Medicine
Geriatrics
Internal Medicine
Hospital Medicine
Neurology
Oncology
Psychiatry
Pediatrics/NICU
Surgery
Other    
* What teams or committees are you a member of in your institution (i.e. Palliative Consult Team, Ethics Committee, etc.)?

Ia. General Applicant Information - Applicant #2 (Chaplain/Spiritual Care Provider)

Contact Information

* Name
* Current Title/Position
Home Address
City/Town
State/Province
ZIP/Postal Code
Country
* Email Address
Phone Number
* Degree/Credentials
* Specialty (i.e. Palliative Care)
* What teams or committees are you a member of in your institution (i.e. Palliative Consult Team, Ethics Committee, etc.)?

II. Institutional Information (complete jointly)

Address

* Employing Institute/Program
* Address
* City/Town
* State/Province
* ZIP/Postal Code
* Country
* Email Address
Phone Number
* Work Setting
Hospital
Out-Patient Clinic
Home Care
Hospice
Long Term Care
Other    

III. Statement of Interest (Complete Jointly)

* Please describe in the space provided why you are interested in participating in the Interprofessional Spiritual Care Education Curriculum (ISPEC) as a team and how you will apply the information in your institution.

IV. Institutional Goals

The primary objective of ISPEC project is to develop participants as experts who will return to their individual institutions, share information with others, engage colleagues to take the on-line course, and impact the quality of care by integrating spirituality as an important element of care.Preparation for completing this objective begins with the development of specific goals.

As part of the application, we ask that you submit, as a team, three realistic and practical goals that you will achieve to improve spiritual care in your institution after attending the course. Goals are highly encouraged to include a measurable component, so that you can determine their impact within your institution. During the course you will have time to discuss and refine your goals but we want your ideas to begin germinating here.

Sample Goal: To establish a monthly educational session on spiritual care for oncology clinicians and to measure satisfaction of the educational session.

* Goal One
* Goal Two
* Goal Three

V. Letter of Support from the Institution's Administrator/Supervisor.

Letter of support should demonstrate the organization's commitment to foster change in clinical care and facilitate the implementation of ISPEC training programs, following completion of the course.

* Please upload your letter of support here: