VA Form 10-2850d Application for Health Professions Trainees

OMB Number: 2900-0205
Estimated Burden: 30 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR HEALTH PROFESSIONS TRAINEES
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER

INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs (VA) to
determine your eligibility for appointment. Type or print in ink. If additional space is needed, please attach a separate sheet and refer to items being answered
by number. Applications for clinical training programs may require additional information. All information required by the training program to which you are
applying, as well as information requested on all application forms, must be included.
VA must protect the safety of our patients. Therefore, at some point in the appointment process, you will be asked questions about your physical and mental
health. This includes questions as to whether you have received tuberculin testing, hepatitis B vaccinations or any other vaccinations.
1A. NAME (Last, First, Middle)

1B. OTHER NAMES USED

2. PRESENT ADDRESS (Include ZIP Code)

3A - PRIMARY PHONE (Include area code)

3B - ALTERNATE PHONE (Include area code)

4. SOCIAL SECURITY NUMBER

5A. PRIMARY EMAIL ADDRESS

5B. ALTERNATE EMAIL ADDRESS

7B. VA TRAINING START DATE (mm/yyyy)

7A. VA TRAINING FACILITY (City, State)

6. DATE OF BIRTH (mm/dd/yyyy)

7C. VA TRAINING END DATE (mm/yyyy)
UNKNOWN

UNKNOWN

II - U.S. MILITARY DUTY STATUS
8A. ARE YOU NOW IN U.S. MILITARY?
YES

8B. ARE YOU IN THE RESERVES OR NATIONAL GUARD?
NO

(If YES, complete 8c)

YES (If YES, complete 8c)

8C. BRANCH OF SERVICE

NO

III - CITIZENSHIP
9B. COUNTRY OF CITIZENSHIP

9A. CITIZENSHIP
U.S. CITIZEN BY BIRTH

NATURALIZED U.S. CITIZEN

NOT A U.S. CITIZEN (Complete item 9B)

NOTE: Complete items 10A, 10B, 10C, or 10D ONLY if you are NOT a U.S. citizen.
10A. IMMIGRANT
"A" NUMBER

10B. EXCHANGE VISITOR
VISA TYPE

VISA NUMBER

10C. OTHER NON-IMMIGRANT
VISA TYPE

VISA NUMBER

10D. FORM DS2019
DO YOU HAVE A VALID DS2019?
YES

DATE

ISSUE DATE

EXPIRATION DATE

ISSUE DATE

EXPIRATION DATE

NO

DATE OF LAST VALIDATION (MM/DD/YYYY)

IV- THIS SECTION TO BE COMPLETED BY DESIGNATED EDUCATION OFFICER (DEO) OR DESIGNEE
11A. The trainee has met all of the criteria of the Trainee Qualifications & Credentials Verification Letter (TQCVL).

YES

NO

11B. Incomplete items on the TQCVL have been addressed and resolved.

YES

NO

11C. Special attention has been given to the following items from the application forms.

11D. Comments:

NO

YES

11E. This applicant has been approved for appointment.

11F. Comments:

12A. SIGNATURE OF FACILITY DESIGNATED EDUCATION OFFICER OR DESIGNEE
VA FORM 10-2850D
NOV 2011

12B. TITLE

12C. DATE

PAGE 1 OF 4

SOCIAL SECURITY NUMBER

LAST NAME, FIRST NAME, MIDDLE NAME

V- LICENSE, CERTIFICATION, OR REGISTRATION IN CURRENT CLINICAL PROFESSION
13A. LIST ALL LICENSES, CERTIFICATIONS,AND REGISTRATIONS, INCLUDING
THE DRUG ENFORCEMENT AGENCY (DEA), THAT YOU HAVE NOW OR HAVE
HAD AS A HEALTH PROFESSIONAL, I.E. MEDICAL, NURSING, PHARMACY, ETC.

13B.
STATE ISSUING
LICENSE

13D.
EXPIRATION DATE
(MM/DD/YYYY)

13C. LICENSE, CERTIFICATION OR
REGISTRATION NUMBER

VI- LICENSE, CERTIFICATION, OR REGISTRATION IN PREVIOUS CLINICAL PROFESSION(S)
14A. LIST ALL LICENSES, CERTIFICATIONS, AND REGISTRATIONS, INCLUDING
DEA, THAT YOU HAVE EVER HAD AS A HEALTH PROFESSIONAL, I.E. MEDICAL,
NURSING, PHARMACY, ETC.

14B.
STATE ISSUING
LICENSE

14C. LICENSE, CERTIFICATION OR
REGISTRATION NUMBER

14D.
EXPIRATION DATE
(MM/DD/YYYY)

15. ENTER YOUR NATIONAL PROVIDER IDENTIFIER (NPI)

The following two questions apply to both your current health profession and any prior health profession.
16. DO YOU HAVE PENDING, OR HAVE YOU EVER HAD ANY LICENSE, CERTIFICATION, OR REGISTRATION TO PRACTICE
(INCLUDING DEA CERTIFICATE) REVOKED, SUSPENDED, DENIED, RESTRICTED, OR PLACED ON A PROBATIONARY STATUS,
OR HAVE YOU EVER VOLUNTARILY RELINQUISHED A LICENSE, CERTIFICATION, OR REGISTRATION IN LIEU OF FORMAL ACTION?

YES - EXPLAIN IN PART XI

NO

17. DO YOU HAVE PENDING, OR HAVE YOU EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH CARE INSTITUTION OR AGENCY
REVOKED, SUSPENDED, DENIED, RESTRICTED, LIMITED, OR PLACED ON A PROBATIONARY STATUS, OR HAVE YOU EVER
VOLUNTARILY RELINQUISHED CLINICAL PRIVILEGES IN LIEU OF FORMAL ACTION?

YES - EXPLAIN IN PART XI

NO

VII - EDUCATION AND TRAINING AFTER HIGH SCHOOL THROUGH GRADUATE / PROFESSIONAL SCHOOL (Continue in Part XI if necessary)
18A. NAME OF SCHOOL

18B. ADDRESS (City, State, and Zip Code)

18C. START
DATE
(MM/YY)

18E.DIPLOMA, DEGREE,
18D.
OR CERTIFICATE
(EXPECTED)
AWARDED OR IN
COMPLETION
PROGRESS
DATE (MM/YY)

18F. MAJOR FIELD
OF STUDY

VIII - GRADUATES OF AN INTERNATIONAL MEDICAL SCHOOL
19A. ARE YOU A GRADUATE OF AN
INTERNATIONAL MEDICAL SCHOOL?
YES
NO

19B. EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG) CERTIFICATE NUMBER

19C. ECFMG CERTIFICATE DATE

IX- INTERNSHIP, RESIDENCY AND FELLOWSHIP TRAINING
20A. NAME OF HOSPITAL OR INSTITUTION

VA FORM 10-2850D
NOV 2011

20B. ADDRESS (City, State and ZIP Code)

20C. SPECIALTY

20D.
START DATE
(MM/YY)

20E.(EXPECTED)
COMPLETION
DATE (MM/YY)

20F.
NUMBER OF
MONTHS
COMPLETED

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LAST NAME, FIRST NAME, MIDDLE NAME

SOCIAL SECURITY NUMBER

X - ADDITIONAL QUESTIONS
ITEM

PLACE AN 'x' IN APPROPRIATE SPACE. IF YES, EXPLAIN DETAILS IN PART XI

21

AS A PARTICIPANT IN THE MEDICARE AND MEDICAID PROGRAMS, HAVE YOU EVER BEEN CONVICTED OF OR
INVESTIGATED FOR MAKING FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS, REPRESENTATIONS, WRITINGS, OR
DOCUMENTS REGARDING THE DELIVERY OF OR PAYMENT FOR HEALTH CARE BENEFITS, ITEMS OR SERVICES THAT
WOULD BE IN VIOLATION OF THE CRIMINAL FALSE CLAIMS ACT?

22

ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL, OR JUDICIAL
PROCEEDINGS IN WHICH MALPRACTICE ON YOUR PART WAS ALLEGED? If yes, give details in Part XI, including name of
action or proceedings, date filed, court or reviewing agency, and the status or outcome of the case concerning those allegations.
Please also provide your explanation of what occurred.

23

AS A PROVIDER OF HEALTH CARE SERVICES, VA HAS AN OBLIGATION TO DETERMINE THAT APPLICANTS ARE
PROPERLY QUALIFIED. MANY ALLEGATIONS OF MALPRACTICE ARE GROUNDLESS AND ANY CONCLUSION
CONCERNING YOUR PROFESSIONAL QUALIFICATIONS WILL BE MADE ONLY AFTER A FULL EVALUATION OF THE
CIRCUMSTANCES.

YES

NO

XI - REMARKS
ITEM
NO.

(Include additional information requested in items above. Be sure to indicate Item number on Form to which the comment refers.)

XII - CERTIFICATION
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,
ALL OF MY STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.

NOTE: A false statement on any part of your application may be grounds for not hiring you, or for terminating you
after you begin work. Also, you may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
24A. SIGNATURE OF APPLICANT (sign in dark ink)

VA FORM 10-2850D
NOV 2011

24B. DATE (mm/dd/yyyy)

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SOCIAL SECURITY NUMBER

LAST NAME, FIRST NAME, MIDDLE NAME

AUTHORIZATION FOR RELEASE OF INFORMATION
In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and
suitability for employment, I:
Authorize VA to make inquiries about me to current and previous employers, educational institutions, state licensing boards,
professional liability insurance carriers, other professional organizations or persons, agencies, organizations, or institutions listed
by me as references, and to any other sources which VA may deem appropriate or be referred by those contacted;
Authorize release of such information and copies of related records and documents to VA officials;
Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries;
Authorize VA to disclose to such persons, employers, institutions, boards, or agencies identifying and other information about me
to enable response to such inquiries; and
Authorize VA to share any information about me with the affiliated institution or training program official.
SIGNATURE OF APPLICANT

DATE

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
Public reporting burden for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching
existing data sources, gathering data, completing, and reviewing the information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW,
Washington, DC 20420. Do not send applications to this address.
AUTHORITY: The information requested on this form and Authorization for Release of Information is solicited under Title 38, United States Code,
Chapters 73 and 74.
PURPOSES AND USES: The information requested on the application is collected to determine your qualifications and suitability for appointment to
a VA clinical training program. If you are appointed by VA, the information will be used to make pay and benefit determinations and in personnel
administration processes carried out in accordance with established regulations and systems of records.
ROUTINE USES: Information on the form may be released without your prior consent outside the VA to another federal, state or local agency. It may
be used to check the National Practitioner Health Integrity and Protection Data Bank (HIPDB) or the List of Excluded Individuals and Entities (LEIE)
maintained by Health and Human Services (HHS), Office of Inspector General (OIG), or to verify information with state licensing boards and other
professional organizations or agencies to assist VA in determining your suitability for a clinical training appointment. This information may also be
used periodically to verify, evaluate, and update your clinical privileges, credentials, and licensure status, to report apparent violations of law, to
provide statistical data, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may be
released without your prior consent to federal agencies, state licensing boards, or similar boards or entities, in connection with the VA's reporting of
information concerning your separation or resignation as a professional staff member under circumstances which raise serious concerns about your
professional competence. Information concerning payments related to malpractice claims and adverse actions which affect clinical privileges also may
be released to state licensing boards and the National Practitioner Data Bank. Information will be stored in a confidential and secure VA database for
purposes of processing your application and may be verified through a computer matching program. Information from this form may also be used to
survey you regarding employment opportunities in VA and to solicit you perceptions about your clinical training experiences at VA and non-VA
facilities.
EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Completion of this form is mandatory
for consideration of your application for a clinical training position in VA; failure to provide this information may make impossible the proper
application of Civil Service rules and regulations and VA personnel policies and may prevent you from obtaining employment, employee benefits, or
other entitlements.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
Disclosure of your Social Security Number (SSN) is mandatory to obtain the employment and benefits that you are seeking. Solicitation of the SSN is
authorized under provisions of Executive Order 9397 dated November 22, 1943. The SSN is used as an identifier throughout your Federal career. It will
be used primarily to identify your records. The SSN also will be used by Federal agencies in connection with lawful requests for information about you
from former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be
used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of
records, 'Applicants for Employment' under Title 38, U.S.C.-VA (02VA135), in the 2003 Compilation of Privacy Act Issuances. The SSN will also be
used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is necessary because of the
large number of Federal employees and applicants with identical names and birth dates whose identities can only be distinguished by the SSN.
VA FORM 10-2850D
NOV 2011

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