VA Form 10-2850d

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OMB Control No. 2900-0205
Estimated Burden: 30 Minutes
Expiration Date: XX/XX/20XX

HEALTH PROFESSIONS TRAINEE
DATA COLLECTION FORM
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT, AND
INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER
INSTRUCTIONS: Please submit this data collection form, 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. Clinical training programs may require additional information from trainees. All information required by the training program to which you have applied,
as well as information requested on all data collection forms, must be included.

SECTION I - APPLICANT INFORMATION
1A. NAME (Last, First, Middle):

1B. OTHER NAMES USED:

2. PRESENT ADDRESS (Include ZIP Code):

3A. PRIMARY PHONE NUMBER (Include Area Code):
3B. ALTERNATE PHONE NUMBER (Include Area Code):

4. SOCIAL SECURITY NUMBER:

5A. PRIMARY EMAIL ADDRESS:

7A. VA TRAINING FACILITY (City, State):

6. DATE OF BIRTH
(MM/DD/YYYY):

5B. ALTERNATE EMAIL ADDRESS:

7B. VA TRAINING START
DATE (MM/DD/YYYY):

7C. VA TRAINING END DATE
(MM/DD/YYYY):

7D. HAVE YOU EVER BEEN EMPLOYED OR
AFFILIATED WITH VA OR ANOTHER
FEDERAL AGENCY, INCLUDING DOD?
YES

NO

SECTION II - U.S. MILITARY DUTY STATUS
8A. ARE YOU IN THE U.S. MILITARY?
YES (If "YES," complete 8C)

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

YES (If "YES," complete 8c)

8C. BRANCH OF SERVICE:

NO

SECTION III - CITIZENSHIP
9B. PLACE OF BIRTH:

9A. CITIZENSHIP:
U.S. CITIZEN BY BIRTH

9C. COUNTRY OF CITIZENSHIP:

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.
10B. EXCHANGE VISITOR

10A. IMMIGRANT
"A" NUMBER:

VISA TYPE:

10D. FORM DS2019

10C. OTHER NON-IMMIGRANT

VISA NUMBER:

VISA TYPE:

VISA NUMBER:

DO YOU HAVE A VALID DS2019?
YES

DATE

ISSUE DATE

(MM/DD/YYYY):

(MM/DD/YYYY):

EXPIRATION DATE
(MM/DD/YYYY):

ISSUE DATE

(MM/DD/YYYY):

EXPIRATION DATE
(MM/DD/YYYY):

NO

DATE OF LAST VALIDATION
(MM/DD/YYYY):

SECTION IV - 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

YES

NO

11C. SPECIAL ATTENTION HAS BEEN GIVEN TO THE FOLLOWING ITEMS FROM THE APPLICATION FORMS:

11D. COMMENTS:

11E. HAS THE MEDICAL CENTER DIRECTOR (or equivalent) APPROVED THIS TRAINEE FOR APPOINTMENT?
11F. COMMENTS:

12A. SIGNATURE OF FACILITY DESIGNATED
EDUCATION OFFICER OR DESIGNEE:

VA FORM
XXX 20XX

10-2850d

12B. TITLE:

12C. DATE (MM/DD/YYYY):

106A

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NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION 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

13C.
LICENSE, CERTIFICATION, OR
REGISTRATION NUMBER

13D.
EXPIRATION DATE

(MM/DD/YYYY)

SECTION VI - LICENSE, CERTIFICATION, OR REGISTRATION IN OTHER/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. 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 Section 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 Section XI)

NO

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

18B.
ADDRESS

(City, State, and Zip Code)

18C.
START DATE

(MM/DD/YYYY)

18D.

(EXPECTED)

COMPLETION DATE

(MM/DD/YYYY)

18E.
DIPLOMA,
DEGREE, OR
CERTIFICATE
AWARDED OR
IN PROGRESS

18F. MAJOR
FIELD OF STUDY

SECTION VIII - GRADUATES OF AN INTERNATIONAL MEDICAL SCHOOL
19A. ARE YOU A GRADUATE OF AN
INTERNATIONAL MEDICAL SCHOOL?
YES

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

19C. ECFMG CERTIFICATE DATE
(MM/DD/YYYY):

NO

VA FORM 10-2850d, XXX 20XX

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NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

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

20B.
ADDRESS

(City, State, and Zip Code)

20C.
SPECIALTY

20D.
START DATE

(MM/DD/YYYY)

20E.

(EXPECTED)

COMPLETION DATE

(MM/DD/YYYY)

20F.
NUMBER OF
MONTHS
COMPLETED

SECTION X - ADDITIONAL QUESTIONS
ITEM NO.

21

CHECK THE APPROPRIATE BOX. IF "YES," EXPLAIN DETAILS IN SECTION XI
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?

YES

NO

YES

NO

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 Section XI,

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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).
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 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.

SECTION XI - REMARKS
ITEM NO.

VA FORM 10-2850d, XXX 20XX

INCLUDE ADDITIONAL INFORMATION REQUESTED IN ITEMS ABOVE.
BE SURE TO INDICATE ITEM NUMBER ON FORM TO WHICH THE COMMENT REFERS.

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NAME (Last, First, Middle)

SOCIAL SECURITY NUMBER

SECTION 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).
23B. DATE (MM/DD/YYYY):

23A. SIGNATURE OF TRAINEE

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,
and consistent with the requirements of the Rehabilitation Act (29 U.S.C. § 701, et seq.), Americans with Disabilities Act of 1990 (ADA) (42 U.S.C. § 12101, et
seq.) and Title II of the Genetic Information Nondiscrimination Act of 2008 (GINA) (42 U.S.C. § 2000ff, et seq.), I:
Authorize VA to make lawful 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 lawful 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 lawfully disclose to such persons, employers, institutions, boards, or agencies identifying and other information about me to enable VA to
make such inquiries; and
Authorize VA to lawfully share any information about me with the affiliated institution or training program official.
SIGNATURE OF TRAINEE

DATE (MM/DD/YYYY):

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0205 and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect
of this collection of information, including suggestions for reducing this burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control
Number 2900-0205 in any correspondence. Do not send your completed VA Form 10-2850d to this email address.
PRIVACY ACT NOTICE:
AUTHORITY: The information requested on this form and Authorization for Release of Information is solicited under Title 38 U.S.C. 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, XXX 20XX

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