Fillable Vha 10 2850a 091998 Fill 10 2850a (U.S. Department of Veterans Affairs)

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Vha 10 2850a 091998 Fill 10 2850a (U.S. Department of Veterans Affairs)

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VA FORM
JUL 2016
10-2850a
Approved Exception To SF 171
OMB No. 2900-0205
Estimated burden: 30 minutes
Expiration Date: 3/31/2006
APPLICATION FOR NURSES AND NURSE ANESTHETISTS
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. NAME (Last, First, Middle)
2. APPLICATION FOR (Check one)
GENERAL PRACTICE SPECIALTY (Identify Below)
3. PRESENT ADDRESS (Street Address 1) APT. NO.STREET ADDRESS 2
COUNTRYZIP CODESTATECITY
4A. RESIDENCE 4B. BUSINESS
4. TELEPHONE NUMBER (Include Area Code)
5. DATE OF BIRTH 6. PLACE OF BIRTH STATE COUNTRY 7. SOCIAL SECURITY NUMBER
8A. CITIZENSHIP
U.S. CITIZEN BY BIRTH NATURALIZED U.S. CITIZEN NOT A U.S. CITIZEN (Complete item 8B)
8B. COUNTRY OF WHICH YOU ARE A CITIZEN
9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
NO (If "YES" complete items 9B and 9C)YES
9B. NAME OF OFFICE WHERE FILED 9C. DATE FILED
10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER 11. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
12E. TYPE OF DISCHARGE12B. DATE TO12A. DATE FROM 12C. SERIAL OR SERVICE NO. 12D. BRANCH OF SERVICE
Other (Explain on separate sheet)HONORABLE
II - REGISTRATION AND CLINICAL PRIVILEGES
(If restricted, limited or probational
in any State(s), explain on
separate sheet)
NO
14. ARE YOU FULLY REGISTERED IN EVERY
STATE IN WHICH YOU ARE NOW REGISTERED
YES
15. DO YOU HAVE PENDING OR HAVE YOU EVER
HAD ANY REGISTRATION TO PRACTICE REVOKED,
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR
ISSUED/PLACED ON A PROBATIONAL STATUS OR
VOLUNTARILY RELINQUISHED
NO (If "YES" explain on separate sheet)YES
16. HAVE YOU EVER HELD A REGISTRATION TO
PRACTICE THAT IS NO LONGER HELD OR
CURRENT
NO
(If "YES" explain on separate sheet)
YES
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
CARE INSTITUTION, AGENCY OR ORGANIZATION
NO (If "YES" explain on separate sheet) YES
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
NO
(If "YES" explain on separate sheet)
YES
III - NURSE ANESTHETIST CERTIFICATION (To be completed by Nurse Anesthetists only)
18A. ARE YOU CERTIFIED AS A
NURSE ANESTHETIST BY THE
COUNCIL ON CERTIFICATION OF
NURSE ANESTHETISTS (CCNA)
NOYES
18B. WHAT IS THE DATE OF YOUR
CERTIFICATION OR MOST RECENT
RECERTIFICATION (GIVE MONTH AND
YEAR)
18C. WHAT IS YOUR AMERICAN ASSOCIATION
OF NURSE ANESTHETISTS (AANA)
IDENTIFICATION NUMBER
18D. HAS YOUR CCNA
CERTIFICATION EVER BEEN
REVOKED
(If "YES" explain
on separate sheet)
YES NO
IV - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
CERTIFICATION:
I certify that I have verified registration with State boards, and cited visa or evidence of citizenship. Board
certification has been verified (if appropriate).
19. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION AS A NURSE ANESTHETIST
REGISTRATION FOR ALL STATES LISTED BY APPLICANT
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
VISA
NATURALIZED CITIZENSHIP
20A. SIGNATURE OF FACILITY DIRECTOR OR DESIGNEE 20B. TITLE 20C. DATE
PAGE 1
13C. EXPIRATION DATE
13.A. LIST ALL STATES/TERRITORIES IN WHICH YOU ARE NOW OR HAVE EVER
BEEN REGISTERED AS A NURSE (If necessary, continue on separate sheet)
13B. REGISTRATION NUMBER
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VA FORM
JUL 2016
10-2850a
V - PROFESSIONAL LIABILITY INSURANCE
21A. PRESENT PROFESSIONAL
LIABILITY INSURANCE CARRIER
21B. DATE
COVERAGE BEGAN
21C. NAME OF PRIOR CARRIER
22. HAS ANY CARRIER EVER CANCELLED,
DENIED OR REFUSED TO RENEW YOUR
INSURANCE
21D. DATES OF COVERAGE
TO
FROM
(If "YES" explain on
separate sheet)
YES
NO
VI - QUALIFICATIONS
BASIC NURSING EDUCATION (Continue on separate sheet if necessary)
23C. LENGTH
OF PROGRAM
23D. DATE
COMPLETED
23E. DIPLOMA OR
DEGREE RECEIVED
23A. NAME OF SCHOOL 23B. ADDRESS (City, State and ZIP Code)
ADDITIONAL EDUCATION (Continue on separate sheet if necessary)
24D. DATE
COMPLETED
24E.
CREDITS
24F.
DEGREE
24C. MAJOR
24B. ADDRESS (City, State and ZIP Code)
24A. NAME OF SCHOOL
25. IS YOUR PROFESSIONAL BIOGRAPHY COMPILED
IF YOUR COLLEGE OR UNIVERSITY STUDY IS NOT A PART OF YOUR
PROFESSIONAL BIOGRAPHY, PLEASE SEND OFFICIAL TRANSCRIPT(S)
NOTE:
NO (If "YES", please forward a copy to the VA) YES
Vll - NURSING EXPERIENCE
26E.
PART-TIME
AVERAGE
HOURS PER
WEEK
26D.
FULL
TIME
26A. EMPLOYER 26B. ADDRESS (City, State and ZIP Code)
26C. POSITION
FROM TO
NAME AND TITLE OF DIRECTOR OF NURSING OR OF OTHER DEPARTMENT TO WHICH YOU WERE ASSIGNED
NAME AND TITLE OF DIRECTOR OF NURSING OR OF OTHER DEPARTMENT TO WHICH YOU WERE ASSIGNED
NAME AND TITLE OF DIRECTOR OF NURSING OR OF OTHER DEPARTMENT TO WHICH YOU WERE ASSIGNED
VlIl - GENERAL INFORMATION
27. NAMES UNDER WHICH YOU WERE EMPLOYED. IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
1.
2.
3.
4.
28. LIST ALL PROFESSIONAL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS, FELLOWSHIPS AND SPECIALTY CERTIFICATION
(If additional space is required, attach separate sheet).
PAGE 2
26F. DATES
EMPLOYED
VA FORM
JUL 2016
10-2850a
IX - REFERENCES
NOTE: LIST 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 PROFESSIONAL QUALIFICATIONS DURING THE PAST FIVE YEARS.
29A. NAME 29B. ADDRESS (Street, City, State and ZIP Code) 29C. AREA CODE/PHONE NO. 29D. BUSINESS OR OCCUPATION
ITEM NO.
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET OF PAPER
YES NO
30.
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?
31.
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.
32.
ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL 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 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 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.)
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 35, 36 or 37 is "YES" give for each offense:
(1) date; (2) charge; (3) place; (4) court and (5) action taken. When answering item 35 or 36, 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.
33.
Within the last five years have you been discharged from any position for any reason?
34.
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?
35.
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or
explosives 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.)
36.
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 35 above?
37.
While in the military service were you ever convicted by a general court-martial?
38.
If you were in the military service in one of these health occupations, did you ever receive a non-judicial punishment (Article
15)?
39.
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.)
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.
X - 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).
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY
STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
CERTIFICATION:
40A. SIGNATURE OF APPLICANT 40B. DATE (Month, Day,Year)
PAGE 3
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VA FORM
JUL 2016
10-2850a
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 licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association,
Federation of State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as
references, and to 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.
DATE
SIGNATURE OF APPLICANT
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 published notices of systems of records.
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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