VA FL 10-341(b) Trainee Qualification and Credentials Verification Lette

DEPARTMENT OF VETERANS AFFAIRS

OMB Number: 2900-0205
Estimated burden: 5 mins
Expiration Date: XX/XX/XXXX

In Reply Refer To:

Director (00)
VA Medical Center
Address
City, State Zip Code
Department, Program, or Sponsoring Entity
Address
City, State, Zip Code
Dear
1. I certify that the information identified below has been verified for the trainees who are listed below
and who are scheduled to receive all or part of their clinical training at a Department of Veterans
Affairs (VA) facility.
Trainee Name(s)

SSN (last 4
numbers)

Discipline of Study
or Specialty

Degree Level or Post
Graduate Year (PGY)

2. In addition, I certify that these trainees:
(a) Are enrolled in the designated training program and have met the criteria for the
specified level of training;
(b) Have satisfactory health to perform the duties of the clinical training program;
(c) Have had tuberculin testing as required by the Center for Disease Control (CDC) or
VA standards;
(d) Have had hepatitis B vaccination or have signed declination waivers;
(e) Have had primary source verification of educational credentials as required by the
admission criteria of the training program;
(f) Have had primary source verification of current license(s), registration(s) including DEA
registration, or certification(s) through the state licensing board(s) and/or national and state
certification bodies as required by the training program;
1

NOTE: Any trainee who does not meet all of the criteria or upon whom all primary source
verification has not been accomplished should be processed on a separate Trainees Qualifications
and Credentials Verification Letter (TQCVL). For these trainees, deficiencies or discrepancies
should be stated explicitly and an explanation provided.

FL 10-341b
FEB 2005

1

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Department, Program, or Sponsoring Entity, Continued
(g) Have had primary source verification of the ECFMG (Educational Council for Foreign
Medical Graduates) certificates as appropriate;
(h) Have provided letters of reference as required by the training program;
(i) Have been screened against the Health and Human Services' Health Integrity and
Protection Databank (HIPDB) as appropriate for licensed trainees;
(j) Have been screened against the Health and Human Services' List of Excluded Individuals
and Entities (LEIE) for all trainees.
3. I will notify the VA Designated Educational Officer within 72 hours of changes in the academic status
of individual trainees, adverse actions that affect the trainee appointment, or changes in health status
that pose a risk to the safety of trainees, other employees, or patients.
4. I certify that all documents pertaining to the listed trainees are maintained on file and available to VA
officials for review.
Sincerely yours,
Name and Title of Sponsoring Entity Program Director

Received by the Designated Education Officer (DEO)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

The information you provide on any individual named above will be
disclosed to the individual on his or her request.
Paperwork Reduction Act and Privacy Act Notices. We are required to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of
information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if
it does not display a currently valid OMB control number.Title 38, United States Code, Chapter 73, grants the VA the authority to request
such information. Please understand that we regard the provision of this information on your part as voluntary. Response is voluntary,
however failure to provide the information may result in our inability to determine the applicant's qualifications. This collection of
information is intended to provide a tool to judge an applicant's suitability for employment. 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. It may be used to check the National
Practitioner Health Integrity and Protection Data Bank (HIPDB) or the list of exclusions, which is maintained by Health and Human
Services (HHS) Office of Inspector General (OIG) on the List of Excluded Individuals and Entities (LEIE), to State licensing boards, and/or
appropriate professional organizations or agencies to assist the VA in determining the suitability of the applicant for a clinical training
appointment. This information may also be used to periodically verify, evaluate and update clinical privileges, credentials 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 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 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 at any time.
FL 10-341b
MAR 2009

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