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To: All Fire Chiefs and Fire Chaplains
North Carolina Fire Service

Dear Fire Chief and Fire Chaplain:

The Board of Directors of The North Carolina Fallen Firefighters Foundation is attempting to establish a data base of Fire Chaplains currently serving fire departments throughout the state of North Carolina. We request your assistance in helping us accomplish an up-to-date Fire Chaplain Data Base resource of information.  To meet the needs of NC fire departments we are developing a chaplaincy network system for a more efficient and expanded fire chaplaincy service.

The establishment of a Fire Chaplain Data Base will accomplish a three-fold purpose:
  1. It will enable the Chief of Chaplaincy of the NCFFF to identify chaplains in specific regions of the state who can be called upon to offer assistance to fire departments in Line of Duty Death incidents and serious firefighter injuries.

  2. It will ascertain chaplains with specific skills who can be used as chaplain training resources.

  3. It will serve as an aid in identifying the training needs of each individual chaplain and in turn facilitate the development of training opportunities for Fire Chaplains throughout the state.
If your fire department presently has a person designated as the Fire Chaplain to your Department, please take a few minutes to complete the following brief survey and return it to the NCFFF at your earliest convenience. The completed survey will be enhanced by both Fire Chief and Fire Chaplain completing the survey together or in consultation with each other for the best survey results.

Please return the completed survey to NCFFF either by e-mail or US Postal Service.

E-mail to GeneWMoore@nc.rr.com
or
US Postal Service at: NC Fallen Firefighters Foundation;
2501 Blue Ridge Road, Suite 150, Raleigh, NC 27607.

Sincerely yours,

Edward P. Brinson, President
North Carolina Fallen Firefighters Foundation
 
Gene W. Moore, Chief of Chaplaincy
North Carolina Fallen Firefighters Foundation

Please complete the Survey and return to me by Thursday, May 22, 2008.
    
 Survey Minimize
Fire Chaplain Data Base Survey

click the printer icon on the bottom right of this form

Please complete the Survey and return by Thursday, May 22, 2008

  1. Fire Chaplain Name: ____________________________________________

  2. Chaplain’s Address:  ____________________________________________

                                  ____________________________________________

  3. Chaplain’s Home Phone:   ________________________________________

  4. Chaplain’s Work Phone:   ________________________________________

  5. Chaplain’s Cell Phone:   _________________________________________

  6. Chaplain’s E-Mail Address:   ______________________________________

  7. Fire Department name and address:





  8. How long has the chaplain been in the Fire Service? ______­­_

  9. How long has the chaplain served as a Fire Chaplain? _______

    A member of NCSFA? Yes ___ No __


  10. What is the chaplain’s religion (Christian, Jewish, Hindu, etc.)?

    Religious denomination?   __________________


  11. Does the chaplain have Ecclesiastical Appointment or Ordination of his/her faith group? 
     Yes ___ No ____

  12. What is the chaplain’s present level of education?

     _____ High School Graduate   ____ College Graduate

    _____ Seminary Graduate       ____ beyond Seminar

    Is the chaplain now a student? Yes ____ No ____


  13. What special additional skills in chaplaincy does the chaplain provide?
    Basic CPE Training ____ CISM Basic ____ NC Licensed Pastoral Counselor #________

    Other


  14. Would your chaplain participate in special training opportunities for Fire Chaplains if they are offered?
    Yes ___ No ___


  15. Would there be financial resources to pay for his/her Fire Chaplaincy training?
    Yes ___ No ___


  16. What kind(s) of training opportunities would specifically meet what your chaplain says is needed to providing better Fire Chaplaincy care for department personnel at this time?







  17. If the fire chaplain were called upon, would he/she be willing to provide assistance in a Line of Duty Death Incident or care in the event of a serious firefighter injury in your region?
    Yes ___ No ___


  18. Would your fire department cover the fire chaplain’s travel expenses to the event?
    Yes ___ No ___


Fire Department’s Fire Chief

____________________________________________


Fire Chief’s e-mail & direct phone contact information

____________________________________________

____________________________________________


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