Fillable Student App Feb 11 2020 (U.S. Department of Veterans Affairs)

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Student App Feb 11 2020 (U.S. Department of Veterans Affairs)

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The Student App Feb 11 2020 (U.S. Department of Veterans Affairs) form is 35 pages long and contains:

  • 10 signatures
  • 44 check-boxes
  • 290 other fields

Country of origin: US
File type: PDF

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STUDENT CHECKLIST
The following information is needed in the ACOS/Education Office for proper processing:
STUDENT NAME: ___________________________________________________________
LAST NAME, First, Middle
STUDENT EMAIL: ___________________________________________________________
SCHOOL: __________________________________________________________________
STUDENT YEAR: ____________________________________________________________
SERVICE ASSIGNED: ________________________________________________________
SUBSPECIALTY WITHIN SERVICE: _____________________________________________
DATES OF ROTATION: FROM: ____________________ TO: ____________________
___________________________________________________________________________
In addition to completing this package, trainees must complete the following checklist and
securely message all applicable additional materials before they can be credentialed:
1. If the trainee is NOT a US Citizen, the trainee MUST include one of the following:
An elec
tronic copy of a J VISA (Exchange VISA) OR
An elec
tronic copy of a permanent (Immigrant) VISA
2. All students:
An elec
tronic copy of the VA required online TMS training certificate
PLEASE NOTE: TIME STAMPED DIGITAL
SIGNATURE ONLY
Revised 01/17/2020
TABLE OF CONTENTS
STUDENTS
1. Am I Eligible? Checklist for Health Professions Trainees (HPTs) Training at VA
Facilities
2. Application for Health Professions Trainee, VA Form 2850-D
Time Stamped digital signature required on pages 3 and 4
3. Declaration for Federal Employment, Optional Form 306
Time Stamped digital signature required on 17a (Applicant’s Signature)
AND 17b (Appointee’s Signature)
4. Without Compensation (WOC) Letter
Time Stamped digital signature required
5. Random Drug Testing Notification and Acknowledgement
Time Stamped digital signature required
6. SF61 - Appointment Affidavits
Time Stamped digital signature required
7. VA Boston Healthcare Personal Identity Verification (PIV) Card Request
Form PIV Credential identity Verification Matrix
8. US Selective Service System Registration
Federal law requires that most males living in the US between the ages of
18 and 26 register with the Selective Service System. Male, for this purpose,
is any individual born male on their birth certificate regardless of current
gender. Males required to register, but who failed to do so by their 26th
birthday, are barred from any position in any Executive Agency. Visit
https://www.sss.gov, print proof of registration and submit with your
credentialing packet.
https://www.sss.gov/Registration/Check-a-Registration/Verification-Form
9. Information Security Rules of Behavior For Organizational Users. Please
read, initial each page and digitally sign the last page.
Am I Eligible?
Checklist for Health Professions Trainees (HPTs) Training at VA Facilities
The Department of Veterans Affairs adheres to all federal Equal Employment Opportunity and Affirmative Action policies. The
Veterans Health Administration (VHA)/Office of Academic Affiliations (OAA) oversees all clinical health professions training
programs. To participate in training at a VA you will receive a Federal Appointment. However, to be appointed you must be eligible.
If you are unable to meet all eligibility requirements below please alert your program.
Complete
Requirement
Description of Eligibility Requirement Name:
(Provide
proof)
US Citizenship or
Documented
Immigrant, Non-
Immigrant or
Exchange Visitor
HPTs receiving a stipend (VA paycheck) must be US citizens. Non-US citizen trainees who are not
VA-paid (known as without compensation-WOC) may be appointed on the condition that they
provide current immigrant, non-immigrant or exchange visitor documents proving that you can
legally reside or work in the United States.
US Social
Security Number
HPTs must have a US social security number (SSN) prior to beginning the VA pre-employment, on-
boarding process. If you have applied, but do not yet have an SSN, you must wait. HPTs not eligible
to apply for an SSN should immediately contact your program and be reassigned.
(Provide
proof)
US Selective
Service System
Registration
Federal law requires that most males living in the US between the ages of 18 and 26 register with
the Selective Service System. Male, for this purpose, is any individual born male on their birth
certificate regardless of current gender. Males required to register, but who failed to do so by their
26th birthday, are barred from any position in any Executive Agency. Visit
https://www.sss.gov to
register, print proof of registration or apply for a Status Information Letter.
Proof of Identity
On-boarding requires two source identification documents (IDs) to prove identity. Documents
must be unexpired and names on both documents must match. For more information visit:
https://www.oit.va.gov/programs/piv/_media/docs/IDMatrix.pdf States have begun issuing Secure
Driver’s Licenses. Be sure yours will be accepted as a Real ID https://www.dhs.gov/real-id
(Provide
proof)
National
Practitioner Data
Bank (NPDB)
HPTs who are currently licensed, or who previously held a license in the same or a different
discipline, must be screened against the NPDB. Visit the site to perform a self-query and confirm
your eligibility for VA appointment. https://www.npdb.hrsa.gov/
(Provide
proof)
List of Excluded
Individuals and
Entities (LEIE)
The Department of Health and Human Services Office of the Inspector General has compiled a list
of individuals excluded from participation in Medicare, Medicaid and all other Federal healthcare
programs. Visit the site to confirm you are NOT on this list https://exclusions.oig.hhs.gov/
(Provide
proof)
Health
Requirements
As a condition of appointment, HPTs must be physically and mentally fit to perform the essential
functions of the training program and immunized following current Center for Disease Control
guidelines and VHA policy: immunizations include; Hepatitis B vaccination, and annual seasonal
influenza vaccination (alternative for influenza vaccination is to wear a mask when at a VA health
care facility).
Fingerprint
HPTs will be fingerprinted and undergo screenings and background investigations. A VA Human
Screening and
Resources Personnel Suitability Specialist will determine suitability. Additional details can be found
Background
here: http://www.archives.gov/federal-register/codification/executive-order/10450.html
Investigation
Drug-Free
Workplace
HPTs do not undergo pre-employment drug screening. However, they are subject to random drug
testing throughout the entire VA appointment period. You will be asked to sign an
acknowledgement document stating you are aware of this practice (see document site below).
VA On-boarding
Documents
Department of Veterans Affairs HPT pre-employment documents include:
Application for Health Professions Trainees (VA 10-2850D)
Declaration for Federal Employment (OF 306)
HPT Random Drug Testing Notification and Acknowledgement memo
These documents and others are available online for review at
https://www.va.gov/oaa/app
-
forms.asp. Falsifying any answer on a Federal document will result in the inability to appoint or
immediate dismissal from the training program.
HPT Instructions V1.1
September 2019
VA FORM 10-2850D
NOV 2011
11E. This applicant has been approved for appointment.
INSTRUCTIONS: Please submit this application 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. Applications for clinical training programs may require additional information. All information required by the training program to which you are
applying, as well as information requested on all application forms, must be included.
VA must protect the safety of our patients. Therefore, at some point in the appointment process, you will be asked questions about your physical and mental
health. This includes questions as to whether you have received tuberculin testing, hepatitis B vaccinations or any other vaccinations.
II - U.S. MILITARY DUTY STATUS
III - CITIZENSHIP
IV- THIS SECTION 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).
PAGE 1 OF 4
7C. VA TRAINING END DATE (mm/yyyy)
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER
OMB Number: 2900-0205
Estimated Burden: 30 minutes
APPLICATION FOR HEALTH PROFESSIONS TRAINEES
7B. VA TRAINING START DATE (mm/yyyy)
10A. IMMIGRANT 10B. EXCHANGE VISITOR
9A. CITIZENSHIP
NOTE: Complete items 10A, 10B, 10C, or 10D ONLY if you are NOT a U.S. citizen.
10C. OTHER NON-IMMIGRANT 10D. FORM DS2019
DO YOU HAVE A VALID DS2019?
12B. TITLE12A. SIGNATURE OF FACILITY DESIGNATED EDUCATION OFFICER OR DESIGNEE 12C. DATE
11B. Incomplete items on the TQCVL have been addressed and resolved.
8A. ARE YOU NOW IN U.S. MILITARY?
1A. NAME (Last, First, Middle)
2. PRESENT ADDRESS (Include ZIP Code)
3A - PRIMARY PHONE (Include area code)
3B - ALTERNATE PHONE (Include area code)
5A. PRIMARY EMAIL ADDRESS 6. DATE OF BIRTH (mm/dd/yyyy)
4. SOCIAL SECURITY NUMBER
UNKNOWN
YES NO
8C. BRANCH OF SERVICE
U.S. CITIZEN BY BIRTH NATURALIZED U.S. CITIZEN NOT A U.S. CITIZEN (Complete item 9B)
9B. COUNTRY OF CITIZENSHIP
"A" NUMBER
DATE
VISA TYPE
VISA NUMBER
ISSUE DATE
EXPIRATION DATE
VISA NUMBERVISA TYPE
ISSUE DATE
EXPIRATION DATE
YES NO
DATE OF LAST VALIDATION (MM/DD/YYYY)
11C. Special attention has been given to the following items from the application forms.
YES
NO
YES
NO
(If YES, complete 8c)
NO
YES
7A. VA TRAINING FACILITY (City, State)
UNKNOWN
11F. Comments:
1B. OTHER NAMES USED
8B. ARE YOU IN THE RESERVES OR NATIONAL GUARD?
YES NO
(If YES, complete 8c)
5B. ALTERNATE EMAIL ADDRESS
11D. Comments:
ANDREW E. BUDSON, MD
ACOS/Education
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signature
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VA FORM 10-2850D
NOV 2011
VII - EDUCATION AND TRAINING AFTER HIGH SCHOOL THROUGH GRADUATE / PROFESSIONAL SCHOOL (Continue in Part XI if necessary)
IX- INTERNSHIP, RESIDENCY AND FELLOWSHIP TRAINING
VIII - GRADUATES OF AN INTERNATIONAL MEDICAL SCHOOL
VI- LICENSE, CERTIFICATION, OR REGISTRATION IN OTHER/PREVIOUS CLINICAL PROFESSION(S)
18F. MAJOR FIELD
OF STUDY
V- LICENSE, CERTIFICATION, OR REGISTRATION IN CURRENT CLINICAL PROFESSION
PAGE 2 OF 4
20F.
NUMBER OF
MONTHS
COMPLETED
20B. ADDRESS (City, State and ZIP Code) 20C. SPECIALTY
20E.(EXPECTED)
COMPLETION
DATE (MM/YY)
18A. NAME OF SCHOOL
18B. ADDRESS (City, State, and Zip Code)
18C. START
DATE
(MM/YY)
18D.
(EXPECTED)
COMPLETION
DATE (MM/YY)
18E.DIPLOMA, DEGREE,
OR CERTIFICATE
AWARDED OR IN
PROGRESS
19A.
ARE YOU A GRADUATE OF AN
INTERNATIONAL MEDICAL SCHOOL?
13C. LICENSE, CERTIFICATION OR
REGISTRATION NUMBER
13D.
EXPIRATION DATE
(MM/DD/YYYY)
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
.
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?
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?
14D.
EXPIRATION DATE
(MM/DD/YYYY)
14A. LIST ALL LICENSES, CERTIFICATIONS, AND REGISTRATIONS, INCLUDING
DEA, THAT YOU HAVE EVER HAD AS A HEALTH PROFESSIONAL, I.E. MEDICAL,
NURSING, PHARMACY, ETC.
14C. LICENSE, CERTIFICATION OR
REGISTRATION NUMBER
14B.
STATE ISSUING
LICENSE
13B.
STATE ISSUING
LICENSE
YES - EXPLAIN IN PART XI NO
YES - EXPLAIN IN PART XI NO
YES NO
19B. EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG) CERTIFICATE NUMBER
19C. ECFMG CERTIFICATE DATE
SOCIAL SECURITY NUMBER
LAST NAME, FIRST NAME, MIDDLE NAME
20A. NAME OF HOSPITAL OR INSTITUTION
15. ENTER YOUR NATIONAL PROVIDER IDENTIFIER (NPI)
20D.
START DATE
(MM/YY)
The following two questions apply to both your current health profession and any prior health profession.
VA FORM 10-2850D
NOV 2011
YES
X - ADDITIONAL QUESTIONS
XI - REMARKS
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.
PAGE 3 OF 4
PLACE AN 'x' IN APPROPRIATE SPACE. IF YES, EXPLAIN DETAILS IN PART XI
21
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?
22
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 Part XI, 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.
23
Do you need accommodations to perform the procedures and essential functions of the training position for which you have applied?
ITEM
NO.
(Include additional information requested in items above. Be sure to indicate Item number on Form to which the comment refers.)
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).
24A. SIGNATURE OF APPLICANT (sign in dark ink)
24B. DATE (mm/dd/yyyy)
ITEM NO
SOCIAL SECURITY NUMBERLAST NAME, FIRST NAME, MIDDLE NAME
TIME STAMPED DIGITAL SIGNATURE ONLY
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signature
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VA FORM 10-2850D
NOV 2011
SOCIAL SECURITY NUMBER
LAST NAME, FIRST NAME, MIDDLE NAME
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.
Public reporting burden for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching
existing data sources, gathering data, completing, and reviewing the information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW,
Washington, DC 20420. Do not send applications to this address.
AUTHORITY: The information requested on this 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 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.
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
SIGNATURE OF APPLICANT DATE
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
PAGE 4 OF 4
In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and
suitability for employment, I:
AUTHORIZATION FOR RELEASE OF INFORMATION
Authorize VA to make 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 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 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 share any information about me with the affiliated institution or training program official.
TIME STAMPED DIGITAL SIGNATURE ONLY
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signature
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Declaration for Federal Employment*
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         
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Declaration for Federal Employment*

Additional Questions
 




  

 

Continuation Space I Agency Optional Questions

 
 
  r 
    




 
 
Certifications I Additional Questions
 




 
  






 
  
 


 






  















MM/DD/YYYY
  








 

 





 
 








PLEASE SIGN 17a AND 17b
APPOINTMENT LETTER FOR TRAINEES
APPOINTED WITHOUT COMPENSATION (WOC)
Date:
Dear
Welcome to the Department of Veterans Affairs, VA Boston Healthcare System.
You will be assigned to our facility as a __________________________ from
_______________ through ______________ under the authority of Title 38 United
States Code (U.S.C.) 7405(a) (1).
In accepting this training assignment, you will receive no monetary
compensation and you will not be entitled to those benefits normally given to
regularly paid employees of the Veterans Health Administration (VHA), such as
leave, health insurance, or retirement.
If you agree to these conditions, please sign the following statement. Either
party may terminate this agreement any time by written notice of such intent.
Sincerely,
DENVER L. AUDYATIS
Chief, Human Resources Management Service
I agree to serve in the preceding capacity under the conditions indicated.
_________________________________________________ ____________
TIME STAMPED DIGITAL SIGNATURE ONLY (Date)
________________________________________________________________
(Printed or Typed Name)
________________________________________________________________
(Home Address – STREET, CITY, STATE ZIP CODE)
________________________________________________________________
(School or Program)
DEPARTMENT OF VETERANS AFFAIRS
VA Boston Healthcare System
1400 VFW Parkway
Boston, Massachusetts 02132
Department of Memorandum
Veterans Affairs
From: VHA Office of Academic Affiliations (OAA)
Subj: Random Drug Testing Notification and Acknowledgement
To: Health Professions Trainee (HPT) in a Testing Designated Positions (TDP)
1. On September 15, 1986, President Reagan signed Executive Order 12564, Drug-Free Federal Workplace,
establishing a policy against the use of illegal drugs by Federal employees, whether on or off duty. In
accordance with the Executive Order, VA has established a Drug-Free Workplace Program to include
random testing for the use of illegal drugs by employees (to include trainees) in sensitive positions.
2. This is to notify you that as an HPT in a sensitive position you may be subject to random drug testing. The
testing procedures, including the collection of a urine specimen, will be conducted in accordance with
Department of Health and Human Services (HHS) Guidelines for Drug Testing Programs.
a. The only VHA Training Programs exempt from Random Drug Testing per policy are:
Clinical Pastoral Education (Chaplain), Social Work, Dietetics, Occupational Therapy, Optometry,
Audiology, Speech Pathology, Non-Clinical and Administrative
3. You can be assured that the quality of testing procedures is tightly controlled, that the test used to confirm
use of illegal drugs is highly reliable and that the test results will be handled with maximum respect for
individual confidentiality, consistent with safety and security.
4. As a trainee subject to random drug testing you should be aware of the following:
Counseling and rehabilitation assistance are available to all trainees through existing Employee
Assistance Programs (EAP) at VA facilities (information on EAP can be obtained from your local Human
Resources office).
You will be given the opportunity to submit supplemental medical documentation of lawful use of an
otherwise illegal drug to a Medical Review Officer (MRO).
VA will initiate termination of VA appointment and/or dismissal from VA rotation proceedings against any
trainee who is found to use illegal drugs on the basis of a verified positive drug test.
Termination and/or dismissal from VA rotation proceedings will be initiated against any trainee who
refuses to be tested.
5. Random testing will begin no sooner than 30 days from the date you sign this acknowledgement.
6. Visit the US Office of Personnel Management (OPM) Work-Life webpage for information on Services
Available for You, Guidance & Legislation as well as Substance User Disorder.
https://www.opm.gov/policy-data-oversight/worklife/employee-assistance-programs/
I acknowledge receiving and reading the notice which states that my position may be designated for
random drug testing, and that, if selected, refusal to submit to testing will result in termination and/or
dismissal from the VA.
____________________________________________________________________________________
Affiliate Training Program
____________________________________
_ Print Name Date
______________________________________
TIME STAMPED DIGITAL SIGNATURE ONLY
WOC STUDENT
Department of Veterans Affairs VA Boston Healthcare System
Primary Identity Source Document Secondary Identity Source Document
• A U.S. Passport or U.S. Passport Card
• A Permanent Resident Card or Alien Registration Receipt
Card (Form I-551)
• A foreign passport
• An Employment Authorization Document that contains a
photograph (Form I-766)
• A Driver’s license or ID card issued by a State or
possession of the United States provided it contains a
photograph
• A U.S. Military card
• A U.S. Military dependent’s ID card
• A PIV Card
Updated 3/28/16
• A U.S. Social Security Card issued by the Social Security Administration
• An original or certified copy of a birth certificate issued by a state,
county, municipality authority, possession or outlying possession of
the U.S. bearing an official seal
• An ID card issued by a federal, state, or local government agency or
entity, provided it contains a photograph
• A voter's registration card
• A U.S. Coast Guard Merchant Mariner Card
• A Certificate of U.S. Citizenship (Form N-560 or N-561)
• A Certificate of Naturalization (Form N-550 or N-570)
• A U.S. Citizen ID Card (Form I-197)
• An Identification Card for Use of Resident Citizen in the United States
(Form I-179)
•
A Certification of Birth Abroad or Certification of Report of Birth issued
by the Department of State (Form FS-545 or Form DS-1350)
• A Temporary Resident Card (Form I-688)
• An Employment Authorization Card (Form I-688A)
• A Reentry Permit (Form I-327)
• A Refugee Travel Document (Form I-571)
• An Employment authorization document issued by Department of
Homeland Security (DHS)
• An Employment Authorization Document issued by DHS with
photograph (Form I-688B)
• A driver's license issued by a Canadian government entity
• A Native American tribal document
PIV Credential Identity Verification Matrix
All identity source documents shall be bound to the applicant and shall be neither expired or cancelled. PIV and Non-PIV credentials require
two forms of identification, one primary and one secondary. The secondary identity source document may be from the primary or
secondary list, but if from the primary list it cannot be of the same type as the primary identity source document example.
Flash Badges may be issued following review of a single primary or secondary identity document including applicant photograph. FIPS 201-2
VA BOSTON HCS PERSONAL IDENTITY VERIFICATION (PIV) CARD REQUEST FORM
Instructions For Use
Card Applicant: Complete Section 1.
PIV Managers/Sponsors: Use Section 2 as needed.
(NOTE: This is a temporary document, for administrative use only, and must be destroyed once the
information is entered in the PIV Enrollment Portal.)
SECTION 1: APPLICANT INFORMATION
PLEASE PRINT THE INFORMATION NEATLY
FULL LEGAL NAME: Last First Middle
DATE OF BIRTH: mm/dd/yyyy:
U.S. SSN (ONLY):
PLACE OF BIRTH (U.S. City & State/Other Country):
HOME TELEPHONE # (Optional):
HOME EMAIL (Optional):
COUNTRY OF CITIZENSHIP:
GENDER:
MALE
FEMALE
RACE (SELECT ONE):
American Indian or Alaskan Native
Asian or Pacific Islander
Black-non-Hispanic
Hispanic
White-non-Hispanic
HEIGHT (Feet &
Inches):
WEIGHT
(Pounds):
EYE COLOR:
HAIR COLOR:
APPLICANT’S SIGNATURE & DATE:
SECTION 2: MANAGERS & SPONSORS (As Needed)
Reminders for PIV Managers & Sponsors:
• If the Applicant is not a U.S. Citizen, be sure to check YES for Foreign National in the PIV Enrollment Portal.
• Check PHYSICAL ACCESS if the applicant is an Employee.
• We recommend that CRITICAL EMPLOYEE be checked for all Employees. The following statement will be on the
back of the card: “To all law enforcement agencies: This Person is a critical employee of the VA and in times of
civil emergency or disaster will be required to be on duty, please allow to work.” (EMERGENCY RESPONDER is not
used for most Employees.)
SELECT APPROPRIATE BLOCK FOR THIS CARD
Foreign National: YES NO
PIV Card
NON-PIV Card
Flash Badge
Logical Access
Physical Access
WORK ADDRESS:
SPONSORING DEPARTMENT:
JOB TITLE:
WORK PHONE:
WORK eMAIL:
COST CENTER:
MAIL ROUTING SYMBOL:
Nick Name
Page 44
Appendix A: Department of Veterans Affairs
Information Security Rules of Behavior For
Organizational Users
1. COVERAGE
a. This Department of Veterans Affairs (VA) Information Security Rules of Behavior (ROB)
identifies the specific responsibilities and expected behavior for organizational users of VA
systems and VA information and information systems as required by OMB Circular A-130,
Appendix I, paragraph 4h (6-7) and VA Directive 6500, VA Cybersecurity Program.
b. Organizational users are VA employees, contractors, researchers, students, volunteers, and
representatives of Federal, state, local or tribal agencies who are authorized to access VA
information and information systems but do not represent a Veteran or claimant.
c. Non-organizational users are users other than users explicitly categorized as organizational
users. These include individuals with a Veteran/claimant power of attorney. Change
Management Agents at the local facility are responsible for on-boarding power of
attorney/private attorneys. The rules of behavior for Non-Organizational Users are identified
in the Department of Veterans Affairs Information Security Rules of Behavior for Non-
Organizational Users.
d. The ROB provides the minimum requirements with which users -of VA information and
information systems must comply and does not supersede any policies of VA facilities or
other agency components that provide higher levels of protection to certain information or
information systems. When appropriate, users may exceed these minimum requirements to
protect VA information and information systems by exercising due diligence and ethical
standards.
2. COMPLIANCE
a. Non-compliance with the ROB may be cause for disciplinary actions. Depending on the
severity of the violation and management discretion, consequences may include restricting
access, suspension of access privileges, reprimand, demotion and suspension from work.
Theft, conversion, or unauthorized disposal or destruction of Federal property or information
may result in criminal sanctions.
b. Unauthorized access, upload, download, change, circumvention, or deletion of information
on VA systems; unauthorized modification VA systems, denying or granting access to VA
systems; unauthorized use on VA systems; or otherwise misusing VA systems or resources
is strictly prohibited. ______
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3. ACKNOWLEDGEMENT
a. The ROB must be signed before access is provided to a new user of VA information and
information systems. Thereafter, the VA ROB must be signed annually by all users of VA
information and information systems. This signature indicates agreement to comply with the
ROB, and refusal to sign VA Information Security ROB will result in denied access to VA
information and information systems. Any refusal to sign the VA Information Security ROB
may have an adverse impact on employment with VA.
b. The ROB may be signed in hard copy or electronically. If signed using the hard copy
method, the user should initial and date each page and provide the information requested
under Acknowledgement and Acceptance. For other Federal, state, local, and tribal agency
users, documentation of a signed ROB will be provided to the VA requesting official.
4. INFORMATION SECURITY RULES OF BEHAVIOR
Access and Use of VA Information Systems
I Will:
• Comply with all federal VA information security, privacy, and records management policies.
• Have NO expectation of privacy in any records that I create or receive, or in my activities
while accessing or using VA information systems.
• Use only VA-approved devices, systems, software, services, and data that I am authorized
to use, including complying with any software licensing or copyright restrictions.
• Follow established procedures for requesting access to any VA computer system and for
notifying my VA supervisor or designee when the access is no longer needed.
• Only use my access to VA information and information systems for officially authorized and
assigned duties.
• Log out of all information systems at the end of each workday.
• Log off or lock any VA computer or console leaving my workstation.
• Only use other Federal government information systems as expressly authorized by the
terms of those systems; personal use is prohibited.
• Only use VA-approved solutions for connecting non-VA-owned systems to VA's network.
The ROB does not create any other right or benefit, substantive or procedural, enforceable by law,
by a party in litigation with the U.S. Government.
c.
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I Will Not:
• Attempt to probe computer systems to exploit system controls or to obtain unauthorized
access to VA sensitive information.
• Engage in any activity that is prohibited by VA Directive 6001, Limited Personal Use of
Government Office Equipment Including Information Technology.
• Have a VA network connection and a non-VA network connection, such as a modem or
phone line or wireless network card, physically connected to any device at the same time
unless the dual connection is explicitly authorized.
• Host, set up, administer, or operate any type of Internet server or wireless access point on
any VA network unless explicitly authorized by my Information System Owner, local Area
Manager (AM) or designee, and approved by my Information System Security Officer
(ISSO).
Protection of VA-Issued Devices
I Will:
• Secure mobile devices (e.g., laptops, tablets, smartphones) and portable storage devices
(e.g., compact discs (CD), digital video discs (DVD), universal serial bus (USB) flash drives.
I Will Not:
• Swap or surrender VA hard drives or other storage devices to anyone other than an
authorized OIT employee.
• Attempt to override, circumvent, alter or disable operational, technical, or management
security configuration controls unless expressly directed to do so by authorized VA staff.
Data Protection
I Will:
• Only use virus protection software, anti-spyware, and firewall/intrusion detection software
authorized by VA.
• Safeguard VA mobile devices and portable storage devices containing VA information, at
work and remotely, using FIPS 140-3 validated encryption (or its successor) unless it is not
technically possible.
• Only use VA-owned or approved storage devices encrypted with FIPS 140-3 (or its
successor) validated encryption, consistent with VA’s approved configuration and security
control requirements to perform VA work.
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• Use VA e-mail in the performance of my duties when issued a VA email account.
• Only use non-VA email when use of a non-VA email account is unavoidable.
• Only disseminate VA information to the public via e-mail when authorized to do so and in the
performance of my duties.
I Will Not:
• Transmit VA sensitive information via wireless technologies unless the connection uses
FIPS 140-3 (or its successor) validated encryption.
• Auto-forward e-mail messages to addresses outside the VA network.
• Download software from the Internet, or other public available sources, offered as free trials,
shareware, or other unlicensed software to a VA-owned system.
• Disable or degrade software programs used by VA that install security software updates on
computer equipment used to connect to VA information systems, or used to create, store or
use VA information.
Teleworking and Remote Access
I Will:
• Keep government furnished equipment (GFE) and VA information safe, secure, and
separated from my personal property and information, regardless of work location. I will
protect GFE from theft, loss, destruction, misuse, and emerging threats.
• Obtain approval prior to using remote access capabilities to connect non-GFE devices to
VA’s network.
• Notify my VA supervisor or designee prior to and upon return from any international travel
with a GFE mobile device (e.g. laptop, smartphone) and comply with any security measures,
including using a specifically configured device issued for international travel and/or
surrendering the device for inspection or reimaging.
• Safeguard VA sensitive information, in any format, device, system and/or software in remote
locations (e.g., at home and during travel).
• Provide authorized OlT personnel access to inspect the remote location pursuant to an
approved telework agreement that includes access to VA sensitive information.
• Protect information about remote access mechanisms from unauthorized use and
disclosure.
• Exercise a higher level of awareness in protecting GFE mobile devices when traveling
internationally as laws and individual rights vary by country and threats against Federal
employee devices may be heightened.
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I Will Not:
• Access non-public VA information technology resources from publicly-available IT
computers, such as remotely connecting to the internal VA network from computers in a
public library.
• Access VA's internal network from any foreign country designated as posing a significant
threat unless approved by my VA supervisor, ISSO, local AM, and Information System
Owner. This prohibition does not affect access to VA external web applications.
User Accountability
I Will:
• Complete mandatory security and privacy awareness training within designated time frames
and complete any additional role-based security training required for my role and
responsibilities.
• Understand that authorized VA personnel may review my conduct or actions concerning VA
information and information systems and take appropriate action.
• Have my GFE scanned and serviced by VA authorized personnel. This may require me to
return it promptly to a VA facility upon demand.
• Permit only those authorized by OlT to perform maintenance on IT components, including
installation or removal of hardware or software.
• Sign specific ROBs as required for access or use of specific VA systems. I may be required
to comply with a non-VA entity's ROB to conduct VA business. While using their system, I
must comply with their ROB.
Sensitive Information
I Will:
• Ensure that all printed material containing VA sensitive information is physically secured
when not in use (e.g., locked cabinet, locked door).
• Only provide access to VA sensitive information to those who have a need-to-know for their
professional duties, including only posting sensitive information to web-based collaboration
tools restricted to those who have a need-to-know and when proper safeguards are in place
for sensitive information.
• Recognize that access to certain databases has the potential to cause great risk to VA, its
customers and employees due to the number and/or sensitivity of the records being
accessed. I will act accordingly to ensure the confidentiality and security of these data
commensurate with this increased potential risk.
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• Obtain approval from my supervisor to use, process, transport, transmit, download, print or
store electronic VA sensitive information remotely (outside of VA owned or managed
facilities (e.g., medical centers, community-based outpatient clinics (CBOC), or regional
offices)).
• Protect VA sensitive information from unauthorized disclosure, use, modification, or
destruction, and will use encryption products approved and provided by VA to protect
sensitive data.
• Transmit VA sensitive information via fax only when no other reasonable means exist, and
when either someone is at the receiving machine to receive the transmission or the
receiving machine is in a secure location.
• Encrypt email, including attachments, that contain VA sensitive information. I will not encrypt
email that does not include VA sensitive information, or any email excluded from the
encryption requirement.
• Protect VA sensitive information aggregated in lists, databases, or logbooks, and include
only the minimum necessary SPI to perform a legitimate business function.
• Ensure fax transmissions are sent to the appropriate destination. This includes double
checking the fax number, confirming delivery, and using a fax cover sheet with the required
notification message included.
I Will Not:
• Disclose any information protected by any of VA’s privacy statutes or regulations without
appropriate legal authority. I understand unauthorized disclosure of this information may
have a serious adverse effect on agency operations, agency assets, and individuals.
• Allow VA sensitive information to reside on non-VA systems or devices unless specifically
designated and authorized in advance by my VA supervisor, ISSO, and Information System
Owner, local AM, or designee.
• Make any unauthorized disclosure of any VA sensitive information through any means of
communication including, but not limited to verbal communications, e-mail, text messaging,
instant messaging, online chat, social media, and web sites.
Identification and Authentication
I Will:
• Use passwords that meet the VA minimum requirements.
• Protect my passwords; verify codes, tokens, and credentials from unauthorized use and
disclosure.
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I Will Not:
• Store my passwords or verify codes in any file on any IT system, unless that file has been
encrypted using FIPS 140-3 (or its successor) validated encryption, and I am the only
person who can decrypt the file. I will not hardcode credentials into scripts or programs.
Incident Reporting
I Will:
• Report suspected or identified information security incidents including unauthorized
disclosures of VA information, or access to a VA information system, as well as anti-virus,
antispyware, firewall or intrusion detection software errors, or significant alert messages
(security and privacy) to my VA supervisor, Information System Security Officer (ISSO) or
designee immediately upon
suspicion.
Social Media & Networking to Conduct Official VA Business
I Will:
• Use the VA intranet to conduct VA business on social media/networking sites wherever
possible.
• Use web-based collaboration and social media tools in accordance with VA Directive 6515,
Use of Web-Based Collaboration Technologies.
• Limit the personal use of social media/networking sites, in accordance with VA Directive
6001, Limited Personal use of Government Office Equipment Including Information
Technology.
• Obtain approval from the Office of Public and Intergovernmental Affairs (OPIA) before
establishing a VA social media account.
• Ensure that my use of social media, to conduct VA business, complies with law, guidance,
and VA policy.
• Be professional at all times when posting to VA-related social media.
• Use my best judgment when interacting on social media about matters related to VA’s
mission.
• In my capacity as a VA representative, post only information about which I have actual
knowledge.
• Identify myself and my roles as a VA representative when commenting or providing
information on matters related to the VA’s mission, and ensure that my profile and any
related content is consistent with how I wish to present myself to colleagues, Veterans, and
the general public.
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• Only post and use content in accordance with applicable ethics, intellectual property,
records, and privacy laws, regulations, and policies.
• Use only instant messaging services approved by VA.
• If content I publish on blogs, wikis or any other form of user-generated media might
reasonably be perceived as the position of VA, publish a disclaimer that the views are my
own and do not represent VA.
I Will Not:
• Comment on VA mission-related legal matters unless I am the VA official spokesperson for
the matter and have management approval to do so.
• In my capacity as a VA representative, comment or provide information on any matter about
which I do not have actual, up-to-date knowledge.
• Post information protected by the Privacy Act of 1974, 38 USC 5701, 5705, or 7332, t
he
H
ealth Insurance Portability and Accountability Act (HIPAA) Rules, or VA policy on any non-
VA websites, without legal authority and prior approval by an authorized official.
• Use profanity, make libelous statements, or use privately-created works without the express,
written permission of the author.
• Quote more than short excerpts of another person’s work unless the source is properly
credited.
5. ACKNOWLEDGEMENT AND ACCEPTANCE
a. I acknowledge that I have received a copy of VA Information Security Rules of Behavior for
Organizational Users.
b. I understand, accept and agree to comply with all terms and conditions of VA Information
Security Rules of Behavior for Organizational Users.
c. These provisions are consistent with and do not supersede, conflict with, or otherwise alter
the employee obligations, rights, or liabilities created by existing statute or Executive order
relating to (1) classified information, (2) communications to Congress, (3) the reporting to
an
I
nspector General of a violation of any law, rule, or regulation, or mismanagement, a gross
waste of funds, an abuse of authority, or a substantial and specific danger to public health or
safety, or (4) any other whistleblower protection. The definitions, requirements, obligations,
rights, sanctions, and liabilities created by controlling Executive orders and statutory
provisions are incorporated into this agreement and are controlling.
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Student App Feb 11 2020 (U.S. Department of Veterans Affairs)

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Completed 16 July 2020

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