VA Form 10-2850e

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OMB Approved No. 2900-0205
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

APPRAISAL OF APPLICANT
VA Burden Statement: An agency may not 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 needed, 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 the burden, to VA Reports Clearance Officer at
[email protected]. Please include OMB Control Number 2900-0205 in any correspondence. Do not send your completed VA Form 10-0205e to this email address.
Privacy Act Notice: Title 38, United States Code, Chapter 73, grants the VA the authority to request such information. Your 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 data to determine 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 (HIPDB) or List of Excepted Individuals (LEIE) Data Banks which are 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 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 that 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.

SECTION A - APPLICANT INFORMATION

1. NAME OF APPLICANT:

2. SOCIAL SECURITY NUMBER:

SECTION B - FOR EMPLOYERS ONLY
3. HOW LONG HAVE YOU KNOWN THE APPLICANT PROFESSIONALLY?

6. DATES OF EMPLOYMENT (MM/DD/YYYY)

5. APPLICANT WAS EMPLOYED:
FULL-TIME

PART-TIME

4. WHAT HAS BEEN YOUR RELATIONSHIP WITH THE APPLICANT?

FROM:

7. AVERAGE HOURS APPLICANT WORKED PER WEEK:

TO:

NOTE: Please check the appropriate rating for each performance factor.
PERFORMANCE FACTORS

UNSATISFACTORY

WEAK

HIGHLY
SATISFACTORY

SATISFACTORY

EXCELLENT

8A. CLINICAL KNOWLEDGE
8B. CLINICAL COMPETENCE/SKILLS
8C. EMOTIONAL STABILITY
8D. ABILITY TO WORK EFFECTIVELY
WITH OTHER STAFF MEMBERS AND
SUPERVISORS
8E. DEPENDABILITY
8F. INSTRUCTIONAL SKILLS
8G. ADMINISTRATIVE COMPETENCE
9. WOULD YOU REHIRE THIS APPLICANT?

10. REASON APPLICANT LEFT YOUR EMPLOYMENT:

NO (If "NO," explain in Remarks)

YES

11. TO YOUR KNOWLEDGE, HAS THE APPLICANT EVER HAD A
LICENSE REVOKED, SUSPENDED, DENIED, RESTRICTED,
LIMITED, OR ISSUED/PLACED IN A PROBATIONAL STATUS?
YES (If "YES," explain in Remarks)

NO

12. TO YOUR KNOWLEDGE, HAS THE
APPLICANT EVER HAD CLINICAL
PRIVILEGES?
YES

NO

13. TO YOUR KNOWLEDGE, HAVE ANY OF THESE
PRIVILEGES EVER BEEN DENIED, REVOKED,
OR VOLUNTARILY RELINGUISHED?
YES (If "YES," explain in Remarks)

NO

SECTION C - FOR EDUCAITONAL INSTITUTIONS ONLY
14. DATE GRADUATED (MM/DD/YYYY):

15. RANK IN CLASS:

16. GRADE POINT AVERAGE:

17. STRONG SUBJECTS:
18. WEAK SUBJECTS:

SECTION D - REMARKS
19. REMARKS:

20. SIGNATURE:

VA FORM
XXX 20XX

10-2850e

21. POSITION:

22. DATE (MM/DD/YYYY):

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