The VA 10-2850c form is a crucial document used by healthcare professionals seeking employment with the Department of Veterans Affairs. This form facilitates the collection of necessary information for credentialing and privileging purposes. If you are ready to take the next step in your career, consider filling out the form by clicking the button below.
The VA 10-2850c form plays a crucial role in the application process for healthcare professionals seeking to work within the Veterans Health Administration. This form is specifically designed for individuals who are applying for or renewing their credentials as part of the VA’s healthcare system. It collects essential information about the applicant’s education, training, and work history, ensuring that the VA can assess qualifications accurately. Additionally, the form requires applicants to disclose any relevant licenses and certifications, which are vital for maintaining the high standards of care expected in the VA system. By providing a comprehensive overview of an applicant's professional background, the VA 10-2850c helps streamline the credentialing process, ultimately benefiting both the healthcare providers and the veterans they serve. Understanding the nuances of this form is essential for anyone looking to navigate the complexities of employment within the VA, as it serves as a gateway to a fulfilling career dedicated to serving those who have served our country.
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Approved Exception To SF 171 OMB No. 2900-0205 Estimated burden: 30 minutes
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
B
C D
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
REGISTERED RESPIRATORY THERAPIST
F
LICENSED PHYSICAL THERAPIST
G
LICENSED PRACTICAL/VOCATIONAL NURSE
H
LICENSED PHARMACIST
PHYSICIAN ASSISTANT EXPANDED-FUNCTION DENTAL AUXILIARY OCCUPATIONAL THERAPIST
OTHER (Specify)
2. NAME (Last, First, Middle)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
4. PRESENT ADDRESS (Include ZIP Code)
STREET ADDRESS 2
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
5B. BUSINESS
CITY
STATE ZIP CODE
COUNTRY
6. DATE OF BIRTH
7. PLACE OF BIRTH (City)
STATE
8. SOCIAL SECURITY NUMBER
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
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
YES
NO
(If "YES" complete items 10B and 10C)
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13A. DATE FROM
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
14C. CURRENT REGISTRATION
YOU ARE NOW OR HAVE EVER BEEN LICENSED
14B. LICENSE NO.
(If "NO" explain on separate sheet)
14D. EXPIRATION DATE
(If not held now, explain on separate sheet)
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE
15B. DO YOU HAVE PENDING OR HAVE YOU EVER HAD A
15C. HAVE YOU EVER HELD A
IN WHICH YOU RECEIVED A LICENSE
STATE LICENSE TO PRACTICE REVOKED, SUSPENDED,
REGISTRATION TO PRACTICE THAT IS
(If restricted, limited or probational in any State(s),
DENIED, RESTRICTED, LIMITED, OR ISSUED/PLACED ON A
NO LONGER HELD OR CURRENT
explain on separate sheet)
PROBATIONAL STATUS OR VOLUNTARILY RELINQUISHED
(If "YES" explain on
NOT APPLICABLE
(If "YES" explain on separate sheet)
NO separate sheet)
16A. NAME THE CERTIFYING BODY FOR YOUR HEALTH OCCUPATION
16B. DATE OF MOST RECENT REGISTRATION/CERTIFICATION (Give Month and Year)
16C. WHAT IS YOUR REGISTRY/ CERTIFICATION NUMBER
16D. HAS ACTION EVER BEEN TAKEN AGAINST YOUR CERTIFICATION OR REGISTRATION
NO (If "YES" explain on
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER
HAD CLINICAL PRIVILEGES AT ANY HEALTH CARE INSTITUTION, AGENCY OR ORGANIZATION
NO (If "YES" complete Item 17B)
17B. NAME 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, OR VOLUNTARILY RELINQUISHED
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 cited visa or evidence of citizenship. Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19A. SIGNATURE OF AUTHORIZED OFFICIAL
19B. TITLE
19C. DATE (MONTH, DAY, YEAR)
VA FORM
10-2850c
EXISTING STOCK OF VA FORM 10-2850c, JUN 2006, WILL BE USED.
PAGE 1
NOV 2016 (R)
IV - LIABILITY INSURANCE (As applicable)
20A. PRESENT LIABILITY
20B. DATE COVERAGE 20C. NAMES OF PRIOR CARRIERS 20D. DATE OF COVERAGE
21. HAS ANY CARRIER EVER
INSURANCE CARRIER
BEGAN
CANCELLED, DENIED OR
FROM
TO
REFUSED TO RENEW YOUR
INSURANCE
V - QUALIFICATIONS
BASIC ALLIED HEALTH EDUCATION (Continue on separate sheet, if necessary)
22A. NAME OF SCHOOL
22B. ADDRESS (City, State and ZIP Code)
22C. LENGTH OF
22D. DATE
PROGRAM
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
23D. DATE
23E. 23F.
CREDITS DEGREE
Vl - PROFESSIONAL EXPERIENCE
24A. EMPLOYER
24B. ADDRESS (City, State and ZIP Code)
24C. POSITION (Where applicable, also specify whether General Practitioner or Specialist)
26D.
FULL-
TIME
26E. PART-TIME
AVERAGE HOURS
PER WEEK
26F. DATES EMPLOYED
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
27B. ADDRESS (Number, Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO.
27D. BUSINESS OR OCCUPATION
PAGE 2
REFERENCES (Continued)
ITEM NO.
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET
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.
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
30.
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?
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives
33.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)?
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.)
37.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
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 Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to State licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of 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.
PAGE 4
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The VA 10-2850c form, also known as the Application for Health Professions Trainees, is an important document for health professionals seeking to work with the Department of Veterans Affairs. However, several misconceptions surround this form. Here’s a breakdown of seven common misunderstandings:
This form is not limited to physicians. It is applicable to a range of health professions, including nurses, pharmacists, and social workers.
While it can be submitted at various points in the application process, it is often most effective when submitted alongside other required documents for a specific position.
In fact, applicants typically need to include supporting documents, such as transcripts and licenses, to provide a complete application.
Applicants may need to update the form periodically, especially if there are changes in their qualifications or professional status.
This form plays a crucial role in the hiring process. It helps the VA assess an applicant's qualifications and suitability for various roles.
While citizenship is a requirement for many positions, non-citizens may also apply if they meet specific eligibility criteria.
The VA 10-2850c may have variations depending on the specific health profession, so it’s important to ensure that the correct version is used.
The VA 10-2850c form is an essential document for healthcare professionals seeking employment with the Department of Veterans Affairs. Alongside this form, there are several other documents that may be required to complete the application process. Below is a list of these forms, each serving a specific purpose.
Each of these forms plays a vital role in the application process for healthcare positions within the VA. Ensuring that all necessary documentation is completed accurately can help streamline the hiring process and support the delivery of quality care to veterans.