The VA 10-2850a form is a crucial document used by healthcare professionals seeking employment with the Department of Veterans Affairs. This application is essential for those aiming to provide care to veterans and ensures that the necessary qualifications and credentials are verified. For individuals ready to take the next step, filling out the form is easy; simply click the button below.
The VA 10-2850a form is an essential document for healthcare professionals seeking to work within the Department of Veterans Affairs (VA). This application form is specifically designed for individuals applying for positions as a nurse, physician, or other medical staff. It collects vital information about the applicant’s qualifications, professional history, and licensure status. By submitting this form, candidates not only demonstrate their commitment to serving veterans but also provide the VA with the necessary details to assess their suitability for employment. Key sections of the form include personal information, educational background, and work experience, along with a section for professional references. Understanding the requirements and properly completing the VA 10-2850a is crucial for those looking to contribute to the healthcare of our nation's veterans.
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 your application process. Ensure you have all the necessary information at hand before you start. This will help streamline the process and avoid any delays.
After submitting the form, you will receive confirmation from the VA. Keep an eye on your email or mailbox for any updates regarding your application status. Timely follow-ups can help ensure a smooth process.
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 collects essential information about the applicant's qualifications, education, and work history.
This form is specifically designed for healthcare providers, including:
The VA 10-2850a form is available online on the official VA website. You can download it in PDF format, print it out, and fill it in. Alternatively, you can request a copy from a local VA facility.
Filling out the form requires attention to detail. Here are some steps to follow:
Along with the VA 10-2850a form, you may need to submit the following documents:
While there is no specific deadline for submitting the form, it is best to apply as soon as possible when a position becomes available. Early submission can improve your chances of being considered for the role.
Once your application is submitted, the VA will review your qualifications. If they find your application meets their requirements, you may be contacted for an interview. The hiring process can take time, so patience is essential.
If you need to make changes after submitting the form, you can contact the VA's human resources department. They will guide you on how to provide updated information or submit a new application if necessary.
If you have questions or need assistance, you can reach out to the VA's human resources department. Additionally, many local VA facilities have staff available to help with the application process.
Missing Required Information: One of the most common mistakes is not filling out all the required fields. Each section is important, so make sure to provide complete information.
Incorrect Social Security Number: Double-check that your Social Security number is accurate. An error here can lead to delays or complications in processing your application.
Not Updating Contact Information: If you've moved or changed your phone number, be sure to update this information. Keeping your contact details current is crucial for communication.
Failing to Sign and Date: It might seem simple, but forgetting to sign and date the form can result in it being returned. Always remember to complete this final step.
Overlooking Supporting Documents: Ensure that you include all necessary supporting documents. Missing these can delay the process or lead to your application being rejected.
The VA 10-2850a form is an important document for healthcare professionals applying for positions within the Department of Veterans Affairs. However, several other forms and documents are often used in conjunction with it to ensure a complete application process. Below is a list of these forms, each serving a specific purpose in the application journey.
These forms and documents collectively support the application process for healthcare professionals seeking to work with the VA. Each one plays a vital role in ensuring that applicants meet the necessary qualifications and standards to serve veterans effectively.
The VA 10-2850a form, used for applying for a VA health care provider position, shares similarities with the VA 10-2850 form. Both documents are designed for health care professionals seeking employment within the Department of Veterans Affairs. They require detailed information about the applicant's qualifications, education, and professional experience. While the VA 10-2850 focuses more on the general application for employment, the VA 10-2850a specifically targets those applying for advanced practice roles, emphasizing the need for additional documentation and credentials pertinent to the position.
Another document similar to the VA 10-2850a is the VA Form 10-5345, which is used to authorize the release of medical information. Both forms require personal information and consent from the applicant. However, while the VA 10-2850a is focused on employment applications, the VA Form 10-5345 is concerned with the sharing of medical records. This distinction highlights the different purposes each form serves within the VA system, despite both being essential for facilitating care and employment processes.
The VA Form 10-10EZ is also comparable to the VA 10-2850a. This form is utilized for enrollment in VA health care and requires personal and financial information from the applicant. Like the VA 10-2850a, it aims to gather comprehensive details to assess eligibility. However, the VA 10-10EZ is primarily for veterans seeking health care services, while the VA 10-2850a is for individuals applying for positions within the VA. Both forms ultimately support the VA's mission to provide care and services to veterans.
Additionally, the VA Form 21-526EZ is another document that bears resemblance to the VA 10-2850a. This form is used by veterans to apply for disability compensation. It requires detailed information about the applicant's service history and medical conditions. While the focus of the VA 21-526EZ is on securing benefits for veterans, the VA 10-2850a is aimed at recruiting qualified health care professionals. Both documents are crucial in the broader context of veteran services, ensuring that veterans receive the necessary support and care.
Finally, the VA Form 10-0480 is similar in that it is used for credentialing health care providers within the VA system. This form collects information regarding the provider's qualifications and experience, much like the VA 10-2850a. However, the VA Form 10-0480 is specifically focused on the verification of credentials for those already in the system, while the VA 10-2850a is for applicants seeking to enter the VA workforce. Both forms play vital roles in maintaining the standards and quality of care provided to veterans.
When filling out the VA 10-2850a form, there are several important considerations to keep in mind. The following list outlines actions to take and avoid during this process.
The VA 10-2850a form is an important document for those seeking employment within the Department of Veterans Affairs. However, there are several misconceptions surrounding this form that can lead to confusion. Here are nine common misunderstandings:
Understanding these misconceptions can help streamline the application process and ensure that all necessary steps are taken. Being informed is key to navigating the requirements successfully.
Filling out the VA 10-2850a form is an important step for healthcare professionals seeking employment with the Department of Veterans Affairs. Here are some key takeaways to keep in mind:
Completing the VA 10-2850a form accurately can significantly impact your job application process. Take your time and ensure that you present yourself in the best possible light.