The VA 10-2850c form is an application used by healthcare professionals to apply for a license to practice at a Department of Veterans Affairs facility. This form is essential for those seeking to provide medical care to veterans. If you're ready to start the application process, fill out the form by clicking the button below.
The VA 10-2850c form plays a crucial role for healthcare professionals seeking employment with the Department of Veterans Affairs (VA). This application form is specifically designed for individuals applying for positions as health care providers, including physicians, nurses, and other medical staff. By completing the VA 10-2850c, applicants provide essential information about their qualifications, including education, training, and professional experience. The form also requires details about licenses and certifications, ensuring that the VA can verify credentials and compliance with regulatory standards. Additionally, applicants must disclose any relevant work history, which helps the VA assess their suitability for various roles within the organization. Understanding the requirements and components of the VA 10-2850c is vital for anyone looking to contribute to the care of veterans, making the application process smoother and more efficient.
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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
Filling out the VA 10-2850c form is an important step for those looking to apply for a position within the Department of Veterans Affairs. It requires careful attention to detail to ensure all information is accurate and complete. Once you have the form in hand, follow these steps to successfully fill it out.
The VA 10-2850c form is an application for health professions scholarship program. It is primarily used by individuals seeking to apply for a scholarship to support their education in health-related fields. The form collects essential information about the applicant's background, qualifications, and the program they wish to pursue.
Anyone applying for a health professions scholarship through the Department of Veterans Affairs (VA) must complete this form. This includes students in fields such as medicine, nursing, pharmacy, and other health professions recognized by the VA.
The form requires personal information such as:
Providing accurate and complete information is crucial for the evaluation of your application.
The VA 10-2850c form can be downloaded from the official VA website. It is also available at VA offices and various educational institutions that offer health profession programs. Ensure you are using the most current version of the form to avoid any processing delays.
Once you have completed the form, you can submit it electronically through the VA's online portal or send a printed copy to the designated VA office. Check the submission guidelines on the VA website for specific instructions and any required documentation that may need to accompany your application.
Yes, there are specific deadlines for submitting the VA 10-2850c form, which may vary depending on the scholarship program you are applying for. It is important to check the VA's website or contact their office for the most current deadlines to ensure your application is considered.
After submission, your application will be reviewed by the appropriate VA officials. You may receive a confirmation of receipt, and the review process may take several weeks. If additional information is needed, the VA will contact you directly.
If you need to update your information after submission, you should contact the VA office handling your application as soon as possible. They will provide guidance on how to make necessary changes and ensure that your application remains accurate and up-to-date.
If your application is denied, you will receive a notification explaining the reasons for the denial. You have the right to appeal the decision. The notification will include instructions on how to file an appeal and any deadlines you need to be aware of.
For additional resources or assistance, you can visit the VA's official website or contact their customer service. Many educational institutions also have financial aid offices that can provide guidance on completing the form and navigating the scholarship application process.
Incorrect Personal Information: Many individuals fail to provide accurate personal details. This includes their name, address, and Social Security number. Double-checking this information can prevent delays in processing.
Missing Signatures: It's common for applicants to forget to sign the form. A missing signature can result in the form being returned, causing further delays. Always review the form to ensure all required signatures are present.
Not Updating Employment History: Some people neglect to update their employment history. This section is crucial for determining eligibility. Be sure to include all relevant job positions and dates of employment.
Ignoring Additional Documentation Requirements: Failing to include necessary supporting documents can lead to complications. Review the checklist provided with the form to ensure you have attached everything required.
The VA 10-2850c form is an essential document used by healthcare professionals seeking to practice within the Department of Veterans Affairs. This form is typically accompanied by several other forms and documents to ensure a comprehensive application process. Below is a list of five common forms and documents that are often used alongside the VA 10-2850c.
These forms and documents collectively support the application process for healthcare professionals seeking to serve veterans. Each plays a specific role in verifying qualifications, ensuring compliance, and facilitating access to necessary resources.
The VA 10-2850c form, known as the Application for Associated Health Occupations, shares similarities with the VA Form 10-2850, which is the Application for Medical Licensure and Credentialing. Both forms are used by healthcare professionals applying for positions within the Department of Veterans Affairs. They require detailed personal information, professional qualifications, and licensure details. The primary difference lies in the specific focus of each form, with the 10-2850c targeting associated health occupations while the 10-2850 is broader, encompassing all medical licensure applicants.
Another related document is the VA Form 10-2850a, which is the Application for Nurse Anesthesia Program. Like the 10-2850c, it is specifically designed for a subset of healthcare professionals. The 10-2850a requires similar information regarding education, work history, and professional credentials. Both forms aim to ensure that applicants meet the necessary qualifications for their respective fields within the VA system.
The VA Form 10-2850b, the Application for the Physician Assistant Program, also parallels the 10-2850c. This form is tailored for those seeking to become physician assistants in the VA. It includes sections that require applicants to provide educational background, clinical experience, and certifications. Both forms focus on ensuring that the applicants possess the necessary qualifications and skills for their specific roles in healthcare.
Similarly, the VA Form 10-2850d, which is the Application for the Occupational Therapy Program, aligns with the 10-2850c in its purpose. This form gathers information from occupational therapy candidates, including their educational history and relevant certifications. Both forms are essential for evaluating the qualifications of applicants who wish to serve veterans in specialized healthcare roles.
The VA Form 10-2850e, the Application for the Physical Therapy Program, shares a similar structure and intent with the 10-2850c. This document is specifically for physical therapists. It collects personal and professional information to assess the qualifications of applicants. Both forms emphasize the importance of having properly credentialed professionals in the VA healthcare system.
Another comparable document is the VA Form 10-2850f, which is the Application for the Speech-Language Pathology Program. This form targets speech-language pathologists and requires similar information as the 10-2850c. It focuses on educational background, certifications, and clinical experience, ensuring that applicants meet the standards necessary for providing care to veterans.
The VA Form 10-2850g, the Application for the Audiology Program, is also similar to the 10-2850c. This form is specifically for audiologists and requires detailed personal and professional information. Both forms are critical for the VA's evaluation process, ensuring that only qualified candidates are considered for roles that directly impact veterans' health.
Lastly, the VA Form 10-2850h, the Application for the Social Work Program, parallels the 10-2850c in its focus on a specific healthcare profession. This form gathers essential information regarding educational qualifications and work experience for social workers. Both forms share the goal of vetting candidates to ensure they are equipped to provide necessary services to veterans.
When filling out the VA 10-2850c form, it's important to follow certain guidelines to ensure your application is processed smoothly. Here are some dos and don'ts to keep in mind:
By following these tips, you can help ensure that your VA 10-2850c form is filled out correctly and submitted successfully.
The VA 10-2850c form is an important document for healthcare professionals seeking to work with the Department of Veterans Affairs. However, several misconceptions surround this form. Below is a list of common misunderstandings along with clarifications.
This form is applicable to various healthcare professionals, including nurses, pharmacists, and therapists, not just physicians.
While the form is necessary for the application process, it does not guarantee employment. Selection is based on various factors, including qualifications and available positions.
This form is typically required for initial applications. However, updates may be necessary if there are significant changes in your credentials or personal information.
While online submission is an option, applicants can also submit a paper version of the form via mail or in person at a VA facility.
This form has specific requirements and purposes distinct from other VA forms. It focuses on verifying credentials for healthcare professionals.
Supporting documents, such as proof of education and licensure, are often required to validate the information provided on the form.
Each job posting may have specific deadlines for submission. It is crucial to check the requirements associated with each application.
Current employees may also need to complete this form if they are applying for a new position or promotion within the VA.
Some applicants may find the form complex. Seeking help from colleagues or VA representatives can ensure accurate completion.
Filling out the VA 10-2850c 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:
By keeping these takeaways in mind, you can approach the VA 10-2850c form with confidence and clarity. Good luck with your application!