Physicians are a vital part of the United States military, and the Department of Veterans Affairs (VA) is responsible for ensuring that all qualified physicians have the opportunity to serve our veterans. In order to apply to become a VA physician, you will need to complete the VA Form Application Physician. The application process is detailed and can seem daunting, but this guide will help you through it step by step. Completing the application correctly is essential in order to be considered for a position with the VA.
Listed below are some facts you might want to check before you start dealing with the va form application physician.
Question | Answer |
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Form Name | Va Form Application Physician |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | 10 2850, veterans administration physician application, how do physicians apply to va for in network application, 10 application 2850 |
Approved Exception To SF 171
OMB No.
Estimated burden: 30 minutes
APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
Affairs to determine your eligibility for appointment in Veterans Health Administration. INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
1. NAME (Last, First, Middle) (Mandatory) |
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2. APPLICATION FOR (Check one) |
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GENERAL PRACTICE |
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SPECIALTY (Identify below) |
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3. PRESENT ADDRESS (Street Address 1) |
STREET ADDRESS 2 |
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APT. NO. |
4. TELEPHONE NUMBER (Include Area Code) |
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CITY |
STATE |
ZIP CODE |
COUNTRY |
4A. RESIDENCE |
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4B. BUSINESS |
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5. DATE OF BIRTH |
6. PLACE OF BIRTH (City) |
STATE COUNTRY |
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7. SOCIAL SECURITY NUMBER (Mandatory) |
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8A. CITIZENSHIP |
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8B. COUNTRY OF WHICH YOU ARE A CITIZEN |
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U.S. CITIZEN BY BIRTH |
NATURALIZED U.S. CITIZEN |
NOT A U.S. CITIZEN (Complete item 8B) |
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9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA |
9B. NAME OF OFFICE WHERE FILED |
9C. DATE FILED |
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YES (If "YES", complete items 9B and 9C) |
NO |
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10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER |
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11. DATE AVAILABLE FOR EMPLOYMENT |
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I - ACTIVE MILITARY DUTY
12A. DATE FROM |
12B. DATE TO |
12C. SERIAL OR SERVICE NO. |
12D. BRANCH OF SERVICE |
12E. TYPE OF DISCHARGE |
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HONORABLE |
OTHER (Explain on separate sheet) |
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II - LICENSURE, DEA/STATE CERTIFICATION, SPECIALTY BOARDS AND CLINICAL PRIVILEGES
13A. LIST ALL STATES/TERRITORIES/COMMONWEALTHS OF THE U. S. OR THE DISTRICT OF COLUMBIA, WHERE YOU ARE OR HAVE EVER BEEN LICENSED (If not held now, explain on a separate sheet)
13B. LICENSE NO.
13C. CURRENT REGISTRATION (If "NO" explain on separate sheet)
YES |
NO |
NOT REQUIRED |
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13D. EXPIRATION
DATE
14. DO YOU HAVE PENDING, OR HAVE YOU |
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15A. NUMBER OF CURRENT OR MOST |
15B. DATE OF |
15C. HAVE YOU EVER HAD A DEA |
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EVER HAD ANY LICENSE REVOKED |
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RECENT DEA (DRUG ENFORCEMENT |
EXPIRATION |
CERTIFICATE OR STATE LICENSE/PERMIT |
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SUSPENDED, DENIED, RESTRICTED, LIMITED |
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ADMINISTRATION) CERTIFICATE AND/OR |
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REVOKED, SUSPENDED, LIMITED, |
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OR ISSUED/PLACED IN A PROBATIONAL |
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STATE LICENSE/PERMIT TO PRESCRIBE |
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RESTRICTED IN ANY WAY OR |
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STATUS OR VOLUNTARILY RELINQUISHED |
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CONTROLLED SUBSTANCES |
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VOLUNTARILY RELINQUISHED |
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YES (If "YES", explain on separate sheet) |
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YES (If "YES", explain on separate sheet) |
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NO |
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NO |
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16A. ARE YOU CERTIFIED BY AN AMERICAN |
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16B. DATE |
16C. SPECIAL CERTIFICATIONS (Recognized |
16D. DATE |
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SPECIALTY BOARD (General Certification) |
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by American Board after exam) |
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YES (If "YES", provide names of boards below) |
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YES (If "YES", provide names of boards below) |
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NO |
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NO |
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16E. LIST AND PROVIDE DETAILS OF ALL CERTIFICATIONS BY OTHER THAN AN AMERICAN SPECIALTY BOARD (Use separate sheet if more space is necessary)
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH CARE INSTITUTION OR AGENCY
YES (If "YES", complete item 17B) |
NO |
17B. NAME AND ADDRESS OF CURRENT OR MOST RECENT INSTITUTION, AGENCY OR ORGANIZATION WHERE HELD
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR CLINICAL PRIVILEGES EVER BEEN DENIED, REVOKED, SUSPENDED, REDUCED, LIMITED, NOT RENEWED, OR VOLUNTARILY RELINQUISHED
YES (If "YES", explain on separate sheet) |
NO |
III - THIS SECTION TO BE COMPLETED BY THE CHIEF OF STAFF
CERTIFICATION: |
I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of |
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citizenship. Board certification has been verified (if appropriate). |
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18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:
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FULL |
CURRENT |
NATURALIZED |
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REGISTRATION |
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LICENSURE |
CITIZENSHIP |
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(All States) |
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BOARD CERTIFICATION
VISA
19A. SIGNATURE OF CHIEF OF STAFF
19B. DATE
VA FORM |
EXISTING STOCK OF VA FORM |
PAGE 1 |
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JUN 2016 (R) |
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IV - PROFESSIONAL LIABILITY INSURANCE
20A. PRESENT PROFESSIONAL LIABILITY INSURANCE CARRIER
20B. DATE COVERAGE BEGAN
20C. NAMES OF PRIOR CARRIERS
20D. DATES OF COVERAGE |
21. HAS ANY CARRIER EVER CANCELLED, |
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DENIED OR REFUSED TO RENEW YOUR |
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FROM |
TO |
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INSURANCE |
(If "YES", explain on |
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YES |
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NO separate sheet) |
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V - PREPROFESSIONAL EDUCATION
22A. NAME OF SCHOOL
22B. ADDRESS (City, State and ZIP Code)
22C. SUBJECT |
22D. YEARS |
22E. GRADUATED |
22F. |
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MAJOR |
ATTENDED |
MONTH |
YEAR |
DEGREE |
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VI - PROFESSIONAL EDUCATION
23A. NAME OF SCHOOL
23B. ADDRESS (City, State and ZIP Code)
23C. YEARS |
23D. GRADUATED |
23E. |
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ATTENDED |
MONTH |
YEAR |
DEGREE |
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NOTE: For items 24 through 27, identify service as a paid Federal employee including service with VA, U.S. Military or Public Health Service. Include and identify internship or general practice residencies. DO NOT include externships.
Vll - RESIDENCY TRAINING AND FELLOWSHIPS SUBSEQUENT TO GRADUATION FROM PROFESSIONAL SCHOOL
24A. NAME OF HOSPITAL
OR INSTITUTION
24B. ADDRESS (City, State and ZIP Code)
24C.
SPECIALTY
24D. PG |
24E. COMPLETED |
24F. |
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NO. OF |
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LEVEL |
MONTH |
YEAR |
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MONTHS |
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VIII - TEACHING AND/OR RESEARCH ASSOCIATIONS AND APPOINTMENTS WITH PROFESSIONAL SCHOOLS
25A. INSTITUTION
25B. ADDRESS (City, State and ZIP Code)
25C. POSITION
25D. DATE FROM
25E. DATE TO
IX - VISITING STAFF HOSPITAL APPOINTMENTS
26A. INSTITUTION
26B. ADDRESS (City, State and ZIP Code)
26C. POSITION
26D. DATE FROM
26E. DATE TO
X - PROFESSIONAL EXPERIENCE
27A. EMPLOYER
27B. ADDRESS (City, State and ZIP Code)
27C. POSITION (Where |
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27E. |
27F. DATES EMPLOYED |
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applicable, also specify |
27D. |
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AVERAGE |
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whether General |
FULL |
HOURS |
FROM |
TO |
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practitioner or Specialist) |
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TIME |
PER WEEK |
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XI - GENERAL INFORMATION
28. NAMES UNDER WHICH YOU WERE EMPLOYED IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
VA FORM |
PAGE 2 |
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JUN 2016 (R) |
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29.LIST ALL PROFESSIONAL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS AND FELLOWSHIPS (If additional space is required, attach separate sheet)
30.REFERENCES: List four persons, preferably in your specialty, living in the United States who are not related to you by blood or marriage and who have been in a position to judge your professional qualifications during the past five years.
30A. NAME
30B. ADDRESS (Street, City, State and ZIP Code)
30C. AREA CODE/PHONE NO. 30D. BUSINESS OR OCCUPATION
ITEM NO. |
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER |
YES |
NO |
31. |
Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based |
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upon military, Federal civilian, or District of Columbia service? |
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32. |
Does the Department of Veterans Affairs (VA) employ any relative of yours (by blood or marriage)? If "YES", give |
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separately such relative's (1) full name; (2) relationship; (3) VA position and employment location. |
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ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL OR JUDICIAL |
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PROCEEDINGS IN WHICH MALPRACTICE ON YOUR PART IS OR WAS ALLEGED? (If "YES" give details including |
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name of action or proceedings, date filed, court or reviewing agency, and the status or disposition of case concerning |
33.allegations, together with your explanation of the circumstances involved.)
(As a provider of health care services, VA has an obligation to exercise reasonable care in determining that applicants are properly qualified. It is recognized that many allegations of professional malpractice are proven groundless. Any conclusion concerning your answer as it relates to professional qualifications will be made only after a full evaluation of the circumstances involved.)
NOTE: A conviction or a discharge does not necessarily mean you cannot be appointed. The nature of the conviction or discharge and how long ago it
occurred is important. Give all the facts so that a decision can be made. If your answer to question 36, 37 or 38 is "YES" give for each offense: (1) date;
(2)charge; (3) place; (4) court and (5) action taken. When answering item 36 or 37, you may omit (1) traffic fines for which you paid a fine of $100.00 or less; (2) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law; (3) any conviction the record of which has been expunged under Federal or State law; and (4) any conviction set aside under the Federal Youth Corrections Act or similar State authority.
34. |
Within the last five years have you been discharged from any position for any reason? |
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35. |
Within the last five years have you resigned or retired from a position after being notified you would be disciplined or |
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discharged, or after questions about your clinical competence were raised? |
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Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives |
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36. |
offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but |
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does not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment |
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of two years or less.) |
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37. |
During the past seven years have you been convicted, imprisoned, on probation or parole, or forfeited collateral, or are you |
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now under charges for any offense against the law not included in 36 above? |
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38. |
While in the military service were you ever convicted by a general |
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39. |
If you were in the military service as a physician, dentist, podiatrist, optometrist, or chiropractor, did you ever receive a |
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Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, |
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and other debts to the U.S. Government, plus defaults on any Federally guaranteed or insured loans such as student and home |
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mortgage loans.) |
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40. |
If “Yes”, explain on a separate sheet the type, length, and amount of the delinquency or default and steps you are taking to |
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correct errors or repay the debt. Give any identification numbers associated with the debt and the address of the Federal |
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agency involved. |
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XII - SIGNATURE OF APPLICANT |
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).
CERTIFICATION: |
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY |
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STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH. |
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41A. SIGNATURE OF APPLICANT
41B. DATE (Month, Day,Year)
VA FORM |
PAGE 3 |
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JUN 2016 (R) |
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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 concerning such information about me to my previous employer(s), current employer, educational institutions, State licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to any other appropriate sources to whom VA may be referred by those contacted or deemed appropriate;
Authorize release of such information and copies of related records and/or 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; and
Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to make such inquiries.
SIGNATURE
DATE
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
AUTHORITY: The information requested on the attached application 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 primarily to determine your qualifications and suitability for employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel administration processes carried out in accordance with established regulations and the published notice of the system of records "Applicants for Employment under Title 38,
ROUTINE USES: Information on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or local agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, and/or appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically verify, evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper request, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may also 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. The information you supply may be verified through a computer matching program at any time.
EFFECTS OF
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW
Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the SSN is authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. 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 your 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. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
VA FORM |
PAGE 4 |
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JUN 2016 (R) |
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