The VA 10-2850c form is a crucial document used by healthcare professionals seeking to apply for a position within the Department of Veterans Affairs. This form collects essential information about the applicant's qualifications and background. If you're ready to take the next step in your career, fill out the form by clicking the button below.
The VA 10-2850c form is an essential document for healthcare professionals seeking to provide services to veterans through the Department of Veterans Affairs (VA). This form serves as a vital tool in the application process for individuals looking to become part of the VA's workforce, specifically for those in medical and healthcare roles. It captures crucial information about the applicant's qualifications, including their education, licensure, and work history. Additionally, the VA 10-2850c helps ensure that the VA can maintain a high standard of care by allowing them to assess the credentials of potential employees thoroughly. Completing this form accurately is not just a bureaucratic step; it reflects the commitment of healthcare providers to serve those who have served our country. As such, understanding the ins and outs of this form is key for any healthcare professional aiming to contribute to the well-being of veterans.
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Approved Exception To SF 171 OMB No. 2900-0205 Estimated burden: 30 minutes
APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs to
determine your eligibility for appointment in Veterans Health Administration.
Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
1.OCCUPATION FOR WHICH APPLYING
A
B
C D
CERTIFIED RESPIRATORY THERAPY TECHNICIAN
E
REGISTERED RESPIRATORY THERAPIST
F
LICENSED PHYSICAL THERAPIST
G
LICENSED PRACTICAL/VOCATIONAL NURSE
H
LICENSED PHARMACIST
PHYSICIAN ASSISTANT EXPANDED-FUNCTION DENTAL AUXILIARY OCCUPATIONAL THERAPIST
OTHER (Specify)
2. NAME (Last, First, Middle)
3. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
4. PRESENT ADDRESS (Include ZIP Code)
STREET ADDRESS 2
APT. NO.
5. TELEPHONE NUMBER (Include Area Code)
5A. RESlDENCE
5B. BUSINESS
CITY
STATE ZIP CODE
COUNTRY
6. DATE OF BIRTH
7. PLACE OF BIRTH (City)
STATE
8. SOCIAL SECURITY NUMBER
9A. CITIZENSHIP
9B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 9B)
10A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
10B. NAME OF OFFICE WHERE FILED
10C. DATE FILED
YES
NO
(If "YES" complete items 10B and 10C)
11. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
12. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
13A. DATE FROM
13B. DATE TO
13C. SERIAL OR SERVICE NO. 13D. BRANCH OF SERVICE
13E. TYPE OF DISCHARGE
HONORABLE
OTHER (Explain on
separate sheet)
II - LICENSURE, DEA CERTIFICATION, REGISTRATION AND CLINICAL PRIVILEGES (As applicable)
14A. LIST ALL STATES/TERRITORIES IN WHICH
14C. CURRENT REGISTRATION
YOU ARE NOW OR HAVE EVER BEEN LICENSED
14B. LICENSE NO.
(If "NO" explain on separate sheet)
14D. EXPIRATION DATE
(If not held now, explain on separate sheet)
NOT REQUIRED
15A. ARE YOU FULLY LICENSED IN EVERY STATE
15B. DO YOU HAVE PENDING OR HAVE YOU EVER HAD A
15C. HAVE YOU EVER HELD A
IN WHICH YOU RECEIVED A LICENSE
STATE LICENSE TO PRACTICE REVOKED, SUSPENDED,
REGISTRATION TO PRACTICE THAT IS
(If restricted, limited or probational in any State(s),
DENIED, RESTRICTED, LIMITED, OR ISSUED/PLACED ON A
NO LONGER HELD OR CURRENT
explain on separate sheet)
PROBATIONAL STATUS OR VOLUNTARILY RELINQUISHED
(If "YES" explain on
NOT APPLICABLE
(If "YES" explain on separate sheet)
NO separate sheet)
16A. NAME THE CERTIFYING BODY FOR YOUR HEALTH OCCUPATION
16B. DATE OF MOST RECENT REGISTRATION/CERTIFICATION (Give Month and Year)
16C. WHAT IS YOUR REGISTRY/ CERTIFICATION NUMBER
16D. HAS ACTION EVER BEEN TAKEN AGAINST YOUR CERTIFICATION OR REGISTRATION
NO (If "YES" explain on
17A. DO YOU CURRENTLY HAVE OR HAVE YOU EVER
HAD CLINICAL PRIVILEGES AT ANY HEALTH CARE INSTITUTION, AGENCY OR ORGANIZATION
NO (If "YES" complete Item 17B)
17B. NAME OF CURRENT OR MOST RECENT INSTITUTION, AGENCY OR ORGANIZATION WHERE HELD
17C. HAVE ANY OF YOUR STAFF APPOINTMENTS OR
CLINICAL PRIVILEGES EVER BEEN DENIED, REVOKED, SUSPENDED, REDUCED, LIMITED, OR VOLUNTARILY RELINQUISHED
III - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
CERTIFICATION: I certify that I have verified licensure and registration with State boards, and cited visa or evidence of citizenship. Board certification has been verified (if appropriate).
18. EVIDENCE HAS BEEN CITED IN REGARDS TO:
CERTIFICATION OR REGISTRATION
VISA
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
LICENSURE/REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
19A. SIGNATURE OF AUTHORIZED OFFICIAL
19B. TITLE
19C. DATE (MONTH, DAY, YEAR)
VA FORM
10-2850c
EXISTING STOCK OF VA FORM 10-2850c, JUN 2006, WILL BE USED.
PAGE 1
NOV 2016 (R)
IV - LIABILITY INSURANCE (As applicable)
20A. PRESENT LIABILITY
20B. DATE COVERAGE 20C. NAMES OF PRIOR CARRIERS 20D. DATE OF COVERAGE
21. HAS ANY CARRIER EVER
INSURANCE CARRIER
BEGAN
CANCELLED, DENIED OR
FROM
TO
REFUSED TO RENEW YOUR
INSURANCE
V - QUALIFICATIONS
BASIC ALLIED HEALTH EDUCATION (Continue on separate sheet, if necessary)
22A. NAME OF SCHOOL
22B. ADDRESS (City, State and ZIP Code)
22C. LENGTH OF
22D. DATE
PROGRAM
COMPLETED
22E. DIPLOMA OR
DEGREE RECEIVED
ADDITIONAL EDUCATION (Continue on separate sheet, if necessary)
23A. NAME OF SCHOOL
23B. ADDRESS (City, State and ZIP Code)
23C. MAJOR
23D. DATE
23E. 23F.
CREDITS DEGREE
Vl - PROFESSIONAL EXPERIENCE
24A. EMPLOYER
24B. ADDRESS (City, State and ZIP Code)
24C. POSITION (Where applicable, also specify whether General Practitioner or Specialist)
26D.
FULL-
TIME
26E. PART-TIME
AVERAGE HOURS
PER WEEK
26F. DATES EMPLOYED
Vll - GENERAL INFORMATION
25. NAMES UNDER WHICH YOU WERE EMPLOYED, IF DIFFERENT FROM NAME GIVEN IN ITEM 1.
26. LIST ALL PUBLICATIONS, SCIENTIFIC PAPERS, HONORS, AWARDS, RESEARCH GRANTS, FELLOWSHIPS (If additional space is required, attach separate sheet).
VlIl - REFERENCES
27.REFERENCES: List at least four persons living in the United States who are not related to you by blood or marriage and who have been in a position to judge your qualifications during the past five years.
27A. NAME
27B. ADDRESS (Number, Street, City, State and ZIP Code)
27C. AREA CODE/PHONE NO.
27D. BUSINESS OR OCCUPATION
PAGE 2
REFERENCES (Continued)
ITEM NO.
PLACE AN "X" IN APPROPRIATE SPACE. IF "YES" EXPLAIN DETAILS ON SEPARATE SHEET
28.Do you receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based upon military, Federal civilian, or District of Columbia service?
29.Does the Department of Veterans Affairs employ any relative of yours (by blood or marriage)? If "YES" give separately such relative's (1) full name; (2) relationship; (3) VA position and employment location.
ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE OR JUDICIAL PROCEEDINGS
IN WHICH MALPRACTICE ON YOUR PART IS OR WAS ALLEGED? (If "YES" give details including name of action or
proceedings, date filed, court or reviewing agency, and the status or disposition of case concerning allegations, together with
30.
your explanation of the circumstances involved.)
(As a provider of health care services, the VA has an obligation to exercise reasonable care in determining that applicants are
properly qualified. It is recognized that many allegations of malpractice are proven groundless. Any conclusion concerning
your answer as it relates to your qualifications will be made only after a full evaluation of the circumstances involved.)
NOTE: A conviction or a discharge does not necessarily mean you cannot be appointed. The nature of the conviction or discharge and how long ago it
occurred is important. Give all the facts so that a decision can be made. If your answer to question 33, 34 or 35 is "YES" give for each offense: (1) date;
(2)charge; (3) place; (4) court and (5) action taken. When answering item 33 or 34, you may omit (1) traffic fines for which you paid a fine of $100.00 or less; (2) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law; (3) any conviction the record of which has been expunged under Federal or State law; and (4) any conviction set aside under the Federal Youth Corrections Act or similar State authority.
31.
Within the last five years have you been discharged from any position for any reason?
32.Within the last five years have you resigned or retired from a position after being notified you would be disciplined or discharged, or after questions about your clinical competence were raised?
Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives
33.offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but does not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment of two years or less.)
34.During the past seven years have you been convicted, imprisoned, on probation or parole, or forfeited collateral, or are you now under charges for any offense against the law not included in 33 above?
35.
While in the military service were you ever convicted by a general court-martial?
36.If you were in the military service in one of these health occupations, did you ever receive a non-judicial punishment (Article 15)?
Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults on any Federally guaranteed or insured loans such as student and home mortgage loans.)
37.If "Yes" explain on a separate sheet the type, length, and amount of the delinquency or default and steps you are taking to correct errors or repay the debt. Give any identification numbers associated with the debt and the address of the Federal agency involved.
IX - SIGNATURE OF APPLICANT
NOTE: A false statement on any part of your application may be grounds for not hiring you, or for terminating you after you begin work. Also, you may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
CERTIFICATION: I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF MY STATEMENTS ARE TRUE, CORRECT, COMPLETE, AND MADE IN GOOD FAITH.
38A. SIGNATURE OF APPLICANT
38B. DATE (Month, Day,Year)
PAGE 3
AUTHORIZATION FOR RELEASE OF INFORMATION
In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and suitability for employment, I:
Authorize VA to make inquiries concerning such information about me to my previous employer(s), current employer, educational institutions, State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to State licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of any other appropriate sources to whom VA may be referred by those contacted or deemed appropriate;
Authorize release of such information and copies of related records and/or documents to VA officials;
Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries; and
Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to make such inquiries.
SIGNATURE
DATE
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
AUTHORITY: The information requested on the attached application form and Authorization for Release of Information is solicited under Title 38, United States Code, Chapters 73 and 74.
PURPOSES AND USES: The information requested on the application is collected primarily to determine your qualifications and suitability for employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel administration processes carried out in accordance with established regulations and the published notice of the system of records "Applicants for Employment under Title 38, U.S.C.-VA" (02VA135)
ROUTINE USES: Information on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or local agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, and/or appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically verify, evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper request, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may also be released without your prior consent to Federal agencies, State licensing boards, or similar boards or entities, in connection with the VA's reporting of information concerning your separation or resignation as a professional staff member under circumstances which raise serious concerns about your professional competence. Information concerning payments related to malpractice claims and adverse actions which affect clinical privileges also may be released to State licensing boards and the National Practitioner Data Bank. The information you supply may be verified through a computer matching program at any time.
EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is voluntary; however, failure to provide this information may delay or make impossible the proper application of Civil Service rules and regulations and VA personnel policies and thus may prevent you from obtaining employment, employees benefits, or other entitlements.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)
Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the SSN is authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. It will be used primarily to identify your records. The SSN also will be used by Federal agencies in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
PAGE 4
Completing the VA 10-2850c form is a straightforward process that requires careful attention to detail. After filling out the form, you will submit it as part of your application process. Ensure that all information is accurate and complete to avoid delays.
What is the VA 10-2850c form?
The VA 10-2850c form is an application used by healthcare professionals to apply for a position within the Department of Veterans Affairs. This form collects essential information about the applicant's qualifications, including education, work history, and professional licenses.
Who needs to fill out the VA 10-2850c form?
This form is required for individuals seeking employment with the VA in various healthcare roles. This includes doctors, nurses, therapists, and other medical personnel. If you are applying for a job that requires a professional license, you will likely need to submit this form.
How do I obtain the VA 10-2850c form?
You can download the VA 10-2850c form from the official VA website. It is available in PDF format, making it easy to print and fill out. Alternatively, you may request a hard copy from your local VA office.
What information do I need to provide on the VA 10-2850c form?
The form requires personal information such as your name, address, and contact details. Additionally, you will need to provide your educational background, work experience, and any relevant licenses or certifications. Be prepared to detail your professional history and any specialized training you have completed.
Is there a fee to submit the VA 10-2850c form?
No, there is no fee associated with submitting the VA 10-2850c form. The application process for VA employment is free of charge. Ensure that you complete the form accurately to avoid any delays in processing.
How long does it take to process the VA 10-2850c form?
The processing time for the VA 10-2850c form can vary. Typically, it takes several weeks to review applications and schedule interviews. Factors such as the number of applications received and the specific position you are applying for can influence the timeline.
Can I update my information after submitting the VA 10-2850c form?
Yes, if you need to update your information after submission, you can do so by contacting the HR department of the VA facility where you applied. They will guide you on how to provide the updated information.
What should I do if I have questions about the VA 10-2850c form?
If you have questions or need assistance while completing the VA 10-2850c form, you can reach out to the VA's Human Resources office. They can provide guidance and clarify any uncertainties you may have regarding the application process.
Is there a deadline for submitting the VA 10-2850c form?
Deadlines for submitting the VA 10-2850c form depend on the specific job posting. Each job listing will indicate the application deadline. It is important to submit your application before this date to be considered for the position.
Filling out the VA 10-2850c form can be a daunting task for many applicants. It is essential to understand common mistakes to ensure a smooth application process. One frequent error occurs when individuals neglect to provide complete contact information. Missing or incorrect phone numbers and email addresses can lead to delays in communication from the Department of Veterans Affairs.
Another common mistake is failing to sign and date the form. An unsigned application is often considered incomplete, which can result in rejection. Applicants should double-check that they have signed the form in the appropriate section before submission.
Many people also overlook the importance of accurately reporting their educational history. Providing incorrect dates or omitting significant details can lead to complications in the review process. It is crucial to list all relevant educational experiences, including degrees earned and institutions attended.
In addition to educational history, applicants sometimes make errors in documenting their work experience. Listing job titles without corresponding dates or descriptions can create confusion. A clear and detailed account of previous employment is vital for the VA to assess qualifications appropriately.
Another mistake is misinterpreting the eligibility requirements. Some individuals may not fully understand the criteria for completing the form, leading to inaccuracies in their responses. It is essential to carefully read the instructions and ensure that all answers align with the eligibility guidelines.
Additionally, applicants may fail to provide the necessary supporting documentation. The VA often requires specific documents to accompany the 10-2850c form. Not including these documents can delay processing or result in outright denial.
People often forget to review their forms for typographical errors. Simple mistakes, such as misspelled names or incorrect Social Security numbers, can have significant repercussions. Taking the time to proofread can prevent unnecessary complications.
Another frequent issue arises when individuals do not keep copies of their submitted forms. Without a record of what was sent, it becomes challenging to follow up on the application status. Keeping a personal copy helps in maintaining accurate records.
Lastly, some applicants submit their forms without fully understanding the implications of their disclosures. The VA 10-2850c form requires individuals to disclose personal information that may affect their eligibility. Understanding what this information entails can help applicants make informed decisions.
The VA 10-2850c form is an essential document for healthcare professionals applying for positions within the Department of Veterans Affairs. To ensure a smooth application process, there are several other forms and documents that are often required or recommended. Below is a list of these forms, each serving a specific purpose in the application and credentialing process.
Having these forms prepared and ready can streamline the application process for positions within the VA. Each document plays a vital role in verifying qualifications and ensuring that the best candidates are selected to provide care for veterans. Being organized and thorough will help applicants navigate the requirements more effectively.
When filling out the VA 10-2850c form, attention to detail is crucial. This form is essential for healthcare professionals seeking to apply for or renew their VA credentials. Here are four important do's and don'ts to consider:
The VA 10-2850c form is an important document used by healthcare professionals applying for positions within the Department of Veterans Affairs. However, several misconceptions surround this form. Here are four common misunderstandings:
Understanding these misconceptions can help applicants navigate the process more effectively and increase their chances of success in securing a position with the VA.
The VA 10-2850c form is essential for healthcare professionals seeking employment with the Department of Veterans Affairs. Here are some key takeaways to consider when filling out and using this form: