Application for Associated Health Occupations

Approved Exception To SF 171
OMB No. 2900-0205
Estimated burden: 30 minutes
Use TAB key or Mouse to move between data fields
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
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 to
determine your eligibility for appointment in Veterans Health Administration.
Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
1. OCCUPATION FOR WHICH APPLYING
A
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
LICENSED PHARMACIST
B
REGISTERED RESPIRATORY THERAPIST
F
PHYSICIAN ASSISTANT
C
LICENSED PHYSICAL THERAPIST
G
EXPANDED-FUNCTION DENTAL AUXILIARY
D
LICENSED PRACTICAL/VOCATIONAL NURSE
H
OCCUPATIONAL THERAPIST
2. NAME (Last, First, Middle)
OTHER (Specify)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
4. PRESENT ADDRESS (Include ZIP Code)
CITY
STATE
6. DATE OF BIRTH
STREET ADDRESS 2
ZIP CODE
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
COUNTRY
7. PLACE OF BIRTH (City)
STATE
SPECIALTY (Identify Below)
5B. BUSINESS
8. SOCIAL SECURITY NUMBER
COUNTRY
9A. CITIZENSHIP
9B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
YES
NO
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
13A. DATE FROM
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
(If "YES" complete items 10B and 10C)
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13B. DATE TO
13C. SERIAL OR SERVICE NO. 13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
HONORABLE
OTHER
(Explain on
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14A. LIST ALL STATES/TERRITORIES IN WHICH
YOU ARE NOW OR HAVE EVER BEEN LICENSED
(If not held now, explain on separate sheet)
14B. LICENSE NO.
14C. CURRENT REGISTRATION
(If "NO" explain on separate sheet)
YES
NO
14D. EXPIRATION DATE
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE IN
WHICH YOU RECEIVED A LICENSE (If restricted, limited or
probational in any State(s),
explain on separate sheet)
15B. DO YOU HAVE PENDING OR HAVE YOU EVER 15C. HAVE YOU EVER HELD A REGISTRATION TO
HAD A STATE LICENSE TO PRACTICE REVOKED, PRACTICE THAT IS NO LONGER HELD OR
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR CURRENT
ISSUED/PLACED ON A PROBATIONAL STATUS OR
VOLUNTARILY RELINQUISHED
(If "YES" explain
(If "YES" explain
YES
NO
NOT APPLICABLE
YES
NO
YES
NO
on separate sheet)
on separate sheet)
16D. HAS ACTION EVER BEEN TAKEN
16A. NAME THE CERTIFYING BODY
16B. DATE OF MOST RECENT
16C. WHAT IS YOUR REGISTRY/
AGAINST YOUR CERTIFICATION OR
FOR YOUR HEALTH OCCUPATION
REGISTRATION/ CERTIFICATION (Give
CERTIFICATION NUMBER
REGISTRATION
Month and Year)
(If "YES" explain
YES
NO
on separate sheet)
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
CARE INSTITUTION, AGENCY OR ORGANIZATION
YES
NO
17B. NAME OF CURRENT OR MOST RECENT
INSTITUTION, AGENCY OR ORGANIZATION WHERE
HELD
(If "YES" complete
Item 17B)
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
VOLUNTARILY RELINQUISHED
(If "YES" explain
YES
NO
on separate sheet)
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
CERTIFICATION:
I certify that I have verified licensure and registration with State boards, and sighted visa or evidence of
citizenship. Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
19A. SIGNATURE OF AUTHORIZED OFFICIAL
VA FORM
JUN 2006 (R)
10-2850c
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19B. TITLE
EXISTING STOCK OF VA FORM 10-2850c, SEP 1998, WILL BE USED.
19C. DATE (MONTH, DAY, YEAR)
PAGE 1
IV - LIABILITY INSURANCE (As applicable)
20A. PRESENT LIABILITY INSURANCE 20B. DATE
20C. NAMES OF PRIOR CARRIERS
CARRIER
COVERAGE BEGAN
20D. DATE OF COVERAGE
FROM
TO
21. HAS ANY CARRIER EVER
CANCELLED, DENIED OR REFUSED
TO RENEW YOUR INSURANCE
YES
NO
(If "YES" explain on separate sheet)
V - QUALIFICATIONS
BASIC ALLIED HEALTH EDUCATION (Continue on separate sheet, if necessary)
22A. NAME OF SCHOOL
22C. LENGTH
OF PROGRAM
22B. ADDRESS (City, State and ZIP Code)
22D. DATE
COMPLETED
22E. DIPLOMA
OR DEGREE RECEIVED
ADDITIONAL EDUCATION (Continue on separate sheet, if necessary)
23A. NAME OF SCHOOL
23B. ADDRESS (City, State and ZIP Code)
23C. MAJOR
Vl - PROFESSIONAL EXPERIENCE
24A. EMPLOYER
24B. ADDRESS
(City, State and ZIP Code)
24C. POSITION
26D.
(Where applicable, also FULLspecify whether General TIME
Practitioner or Specialist)
23D. DATE
COMPLETED
26E.
PART-TIME
AVERAGE
HOURS
PER WEEK
23E.
CREDITS
23F.
DEGREE
26F.
DATES EMPLOYED
FROM
TO
Vll - GENERAL INFORMATION
25. NAMES UNDER WHICH YOU WERE EMPLOYED, IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
26. LIST ALL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS, FELLOWSHIPS (If additional space is required, attach separate sheet).
VlIl - REFERENCES
27. REFERENCES: List at least four persons 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 qualifications during the past five years.
27A. NAME
VA FORM
JUN 2006 (R)
10-2850c
27B. ADDRESS (Number, Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO. 27D. BUSINESS OR OCCUPATION
PAGE 2
REFERENCES (Continued)
27A. NAME
27B. ADDRESS (Number. Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO. 27D. BUSINESS OR OCCUPATION
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET
ITEM NO.
YES
28.
Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based
upon military, Federal civilian, or District of Columbia service ?
29.
Does the Department of Veterans Affairs employ any relative of yours (by blood or marriage)? If "YES" give separately
such relative's (1) full name; (2) relationship; (3) VA position and employment location.
30.
NO
ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE OR JUDICIAL PROCEEDINGS
IN WHICH MALPRACTICE ON YOUR PART IS OR WAS ALLEGED? (If "YES" give details including name of action
or proceedings, date filed, court or reviewing agency, and the status or disposition of case concerning allegations, together
with your explanation of the circumstances involved.)
(As a provider of health care services, the VA has an obligation to exercise reasonable care in determining that applicants
are properly qualified. It is recognized that many allegations of malpractice are proven groundless. Any conclusion
concerning your answer as it relates to your 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 33, 34 or 35 is "YES" give for each offense: (1)
date; (2) charge; (3) place; (4) court and (5) action taken. When answering item 33 or 34, 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.
31.
Within the last five years have you been discharged from any position for any reason?
32.
Within the last five years have you resigned or retired from a position after being notified you would be disciplined or
discharged, or after questions about your clinical competence were raised?
33.
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or
explosives offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding
one year, but does not include any offense classified as a misdemeanor under the laws of a State and punishable by a term
of imprisonment of two years or less.)
34.
During the past seven years have you been convicted, imprisoned, on probation or parole, or forfeited collateral, or are you
now under charges for any offense against the law not included in 33 above?
35.
While in the military service were you ever convicted by a general court-martial?
36.
If you were in the military service in one of these health occupations, did you ever receive a non-judicial punishment (Article
15)?
37.
Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of
benefits, and other debts to the U.S. Government, plus defaults on any Federally guaranteed or insured loans such as
student and home mortgage loans.)
If "Yes" explain on a separate sheet the type, length, and amount of the delinquency or default and steps you are taking to
correct errors or repay the debt. Give any identification numbers associated with the debt and the address of the Federal
agency involved.
IX - 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
STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
38A. SIGNATURE OF APPLICANT (Sign in dark ink)
VA FORM
JUN 2006 (R)
10-2850c
38B. DATE (Month,Day,Year)
PAGE 3
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, U.S.C.-VA" (02VA135)
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 NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is
voluntary; however, failure to provide this information may delay or make impossible the proper application of Civil Service rules and regulations and
VA personnel policies and thus may prevent you from obtaining employment, employees benefits, or other entitlements.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
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
JUN 2006 (R)
10-2850c
PAGE 4