Chaplain Hours may now be submitted online here.
Please complete the following information and click "submit" when completed.
For a printable version of this form, please click here (requires Acrobat Reader)
 

Month
Patient
Chaplain Name

Chaplain Services Provided:

Prayed with pt. Discussed closure with pt./family Counseled concerning spiritual issues Reviewed life events Read from Bible or Counseled about family concerns Communion with pt. Other    please describe

Date

Comments

Mileage

Total Time