The VA 10-2850a form is a crucial document used by healthcare professionals seeking to apply for positions within the Department of Veterans Affairs. This form collects essential information about your qualifications and experience, ensuring that veterans receive the best possible care. If you're ready to take the next step in your career, fill out the form by clicking the button below.
The VA 10-2850a form is an essential document for healthcare professionals seeking to work with the Department of Veterans Affairs. This form plays a critical role in the application process for those who wish to provide medical services to veterans. It collects important information about the applicant's qualifications, including education, training, and professional experience. Additionally, the form requires details about any licenses or certifications held by the applicant, ensuring that only qualified individuals can deliver care to veterans. Completing the VA 10-2850a accurately is crucial, as it helps streamline the hiring process and ensures compliance with VA standards. Furthermore, this form is often accompanied by supporting documents, such as transcripts and licenses, which must be submitted alongside the application. Understanding the importance of the VA 10-2850a can significantly impact a healthcare professional's ability to serve those who have served our country.
OMB Control No. 2900-0205
Use TAB key or Mouse to move between data fields Estimated Burden: 30 minutes
Expiration Date: 05/31/2026
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)
STREET ADDRESS 2
APT. NO.
4. TELEPHONE NUMBER (Include Area Code)
CITY
STATE
ZIP CODE
COUNTRY
4A. RESIDENCE
4B. BUSINESS
5. DATE OF BIRTH
6. PLACE OF BIRTH
STATE COUNTRY
7. SOCIAL SECURITY
NUMBER
8A. CITIZENSHIP
8B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 8B)
9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
9B. NAME OF OFFICE WHERE FILED
9C. DATE FILED
YES
NO (If "YES" complete items 9B and 9C)
10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
11. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
12A. DATE FROM
12B. DATE TO
12C. SERIAL OR SERVICE NO. 12D. BRANCH OF SERVICE
II - REGISTRATION AND CLINICAL PRIVILEGES
12E. TYPE OF DISCHARGE
HONORABLE Other (Explain on separate sheet)
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
13C. EXPIRATION DATE
14. ARE YOU FULLY REGISTERED IN EVERY
15. DO YOU HAVE PENDING OR HAVE YOU EVER
16. HAVE YOU EVER HELD A REGISTRATION TO
STATE IN WHICH YOU ARE NOW REGISTERED
HAD ANY REGISTRATION TO PRACTICE REVOKED,
PRACTICE THAT IS NO LONGER HELD OR
(If restricted, limited or probational
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR
CURRENT
ISSUED/PLACED ON A PROBATIONAL STATUS OR
in any State(s), explain on
VOLUNTARILY RELINQUISHED
NO separate sheet)
NO (If "YES" explain on separate sheet)
NO
(If "YES" explain on separate sheet)
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
17B. NAME OF CURRENT OR MOST RECENT
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
INSTITUTION, AGENCY OR ORGANIZATION WHERE
OR CLINICAL PRIVILEGES EVER BEEN DENIED,
CARE INSTITUTION, AGENCY OR ORGANIZATION
HELD
REVOKED, SUSPENDED, REDUCED, LIMITED, OR
III - NURSE ANESTHETIST CERTIFICATION (To be completed by Nurse
Anesthetists only)
18A. ARE YOU CERTIFIED AS A
18B. WHAT IS THE DATE OF YOUR
18C. WHAT IS YOUR AMERICAN ASSOCIATION
18D. HAS YOUR CCNA
NURSE ANESTHETIST BY THE
CERTIFICATION OR MOST RECENT
OF NURSE ANESTHETISTS (AANA)
CERTIFICATION EVER BEEN
COUNCIL ON CERTIFICATION OF
RECERTIFICATION (GIVE MONTH AND
IDENTIFICATION NUMBER
REVOKED
(If "YES" explain
NURSE ANESTHETISTS (CCNA)
YEAR)
on separate sheet)
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
VISA
REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
20A. SIGNATURE OF FACILITY DIRECTOR OR DESIGNEE
20B. TITLE
20C. DATE
VA FORM
10-2850a
PAGE 1
MAY 2023
V - PROFESSIONAL LIABILITY INSURANCE
21A. PRESENT PROFESSIONAL
21B. DATE
21C. NAME OF PRIOR CARRIER 21D. DATES OF COVERAGE
22. HAS ANY CARRIER EVER CANCELLED,
LIABILITY INSURANCE CARRIER
COVERAGE BEGAN
DENIED OR REFUSED TO RENEW YOUR
FROM
TO
INSURANCE
(If "YES" explain on
separate sheet)
VI - QUALIFICATIONS
BASIC NURSING EDUCATION (Continue on separate sheet if necessary)
23A. NAME OF SCHOOL
23B. ADDRESS (City, State and ZIP Code)
23C. LENGTH OF PROGRAM
23D. DATE
COMPLETED
ADDITIONAL EDUCATION (Continue on separate sheet if necessary)
24A. NAME OF SCHOOL
24B. ADDRESS (City, State and ZIP Code)
24C. MAJOR
24D. DATE
24E.
24F.
CREDITS
DEGREE
25. IS YOUR PROFESSIONAL BIOGRAPHY COMPILED
NOTE:
IF YOUR COLLEGE OR UNIVERSITY STUDY IS NOT A PART OF YOUR
NO (If "YES", please forward a copy to the VA)
PROFESSIONAL BIOGRAPHY, PLEASE SEND OFFICIAL TRANSCRIPT(S)
Vll - NURSING EXPERIENCE
26D.
26E.
26F. DATES
26A. EMPLOYER
26B. ADDRESS (City, State and ZIP Code)
26C. POSITION
PART-TIME
EMPLOYED
FULL
AVERAGE
TIME
HOURS PER
WEEK
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
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
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.
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
32.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?
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or
35.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)?
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.)
39.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.
40A. SIGNATURE OF APPLICANT
40B. 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, 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 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 lawful 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 lawfully disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to make such inquiries.
SIGNATURE OF APPLICANT
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 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.
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Completing the VA 10-2850a form is an important step in the application process. This form is essential for individuals seeking specific roles within the Department of Veterans Affairs. Ensure that all required sections are filled out accurately to avoid delays in processing.
What is the VA 10-2850a form?
The VA 10-2850a form is an application used by healthcare professionals to apply for employment with the Department of Veterans Affairs (VA). This form is specifically designed for individuals seeking positions as nurses, physicians, and other healthcare providers within the VA system.
Who needs to fill out the VA 10-2850a form?
Healthcare professionals who are applying for jobs within the VA must complete the VA 10-2850a form. This includes registered nurses, nurse practitioners, physicians, and other related roles. It is essential for anyone looking to work in a clinical capacity at a VA facility.
Where can I obtain the VA 10-2850a form?
The VA 10-2850a form can be downloaded from the official VA website. It is available in PDF format, making it easy to fill out electronically or print for manual completion. Ensure you are using the most current version of the form to avoid any issues during the application process.
What information is required on the VA 10-2850a form?
The form requires personal information such as your name, contact details, and Social Security number. Additionally, you will need to provide details about your education, professional experience, and any licenses or certifications you hold. It is important to be thorough and accurate when completing this form.
Is there a fee associated with submitting the VA 10-2850a form?
No, there is no fee for submitting the VA 10-2850a form. This application is a part of the employment process with the VA, and there should be no costs incurred for applying through this form.
How long does it take to process the VA 10-2850a form?
The processing time for the VA 10-2850a form can vary depending on several factors, including the specific position applied for and the volume of applications being processed. Generally, applicants can expect to receive updates on their application status within a few weeks after submission.
What should I do if I make a mistake on the VA 10-2850a form?
If you realize that you made an error on your VA 10-2850a form, it is important to correct it as soon as possible. You can either cross out the mistake and write the correct information or submit a new form if the error is significant. Make sure to clearly indicate any changes to avoid confusion during processing.
Can I submit the VA 10-2850a form electronically?
Yes, many applicants can submit the VA 10-2850a form electronically, depending on the specific application process for the position. Some VA facilities may allow for online submissions, while others may require a printed version to be mailed or delivered in person. Always check the specific instructions for the job you are applying for.
What happens after I submit the VA 10-2850a form?
After submitting the VA 10-2850a form, your application will be reviewed by the hiring team at the VA. They will assess your qualifications and determine whether to move forward with an interview or additional steps in the hiring process. You may receive communication regarding your application status or any further requirements.
When filling out the VA 10-2850a form, many people make common mistakes that can delay the application process. One frequent error is not providing accurate personal information. Ensure that your name, address, and contact details are correct. A simple typo can lead to significant issues later on.
Another mistake involves failing to sign and date the form. It may seem minor, but an unsigned form is often considered incomplete. Always double-check that you have signed and dated the application before submission.
Some individuals neglect to include all required documentation. The VA 10-2850a form requests specific supporting documents. Missing these can lead to delays or even denials. Review the checklist provided with the form to ensure you have everything needed.
Inaccurate employment history is another common issue. When detailing your work experience, be precise about your job titles, dates of employment, and responsibilities. Inconsistencies can raise red flags and complicate the review process.
Many applicants also overlook the importance of clarity in their responses. Ambiguous answers can confuse reviewers. Be as clear and concise as possible when answering questions on the form.
Additionally, some people forget to review the form for completeness. After filling it out, take a moment to go through each section. Ensure that every question has been answered and that you haven’t skipped any critical information.
Another mistake is not keeping a copy of the submitted form. It’s essential to have a record of what you submitted for your own reference. This can help if any issues arise later in the process.
Finally, some applicants fail to follow up after submission. It’s wise to check the status of your application a few weeks after sending it in. This proactive approach can help identify any problems early on.
The VA 10-2850a form is an essential document for healthcare professionals seeking to provide services at Veterans Affairs facilities. It serves as an application for a license to practice, and often, it is accompanied by other forms and documents to ensure a complete application package. Below is a list of commonly used forms and documents that may be required alongside the VA 10-2850a.
Understanding these forms and their purposes can significantly streamline the application process for healthcare professionals. Ensuring all necessary documents are completed and submitted can lead to a smoother transition into serving veterans effectively.
The VA Form 10-2850a is an application used by individuals seeking to become a part of the VA healthcare system as a healthcare provider. Several other forms share similarities with the VA 10-2850a, primarily in their purpose of collecting personal and professional information. Below is a list of seven documents that are comparable to the VA 10-2850a form:
Each of these forms serves a specific purpose within the VA system, yet they all share the commonality of requiring detailed personal information to facilitate the processing of applications and claims.
When filling out the VA 10-2850a form, it’s important to approach the process with care and attention to detail. This form is essential for those seeking to provide healthcare services to veterans, and getting it right can make a significant difference in your application. Here’s a list of things to do and avoid:
By following these guidelines, you can enhance the likelihood of a smooth application process. Attention to detail is key, and taking the time to do it right pays off in the long run.
The VA 10-2850a form, also known as the Application for Nurses and Nurse Anesthetists, is essential for healthcare professionals seeking employment with the Department of Veterans Affairs. However, several misconceptions surround this form. Here are nine common misunderstandings:
Understanding these misconceptions can help applicants navigate the process more effectively and improve their chances of securing a position with the VA.
Filling out the VA 10-2850a form can seem daunting, but it’s an important step for healthcare professionals seeking to work with the Department of Veterans Affairs. Here are some key takeaways to keep in mind:
By keeping these takeaways in mind, you can navigate the VA 10-2850a form with confidence. Good luck with your application!