The VA 10-2850a form is an essential document for healthcare professionals looking to work within the Department of Veterans Affairs. This form, specifically designed for application to positions such as physicians, dentists, nurses, and other healthcare roles, gathers comprehensive information from applicants to ensure they meet the stringent qualifications required for VA employment. For those ready to take the next step in their career with the VA, completing the VA 10-2850a is your doorway to making a significant impact on the lives of veterans. Click the button below to fill out the form.
For individuals seeking to work within the Veterans Health Administration, which is a segment of the Department of Veterans Affairs tasked with providing healthcare services to America's veterans, the completion of the VA 10-2850a form is a critical step. This form, specifically designed for healthcare professionals, plays a pivotal role in the hiring process. It gathers essential details about the candidate's qualifications, past employment, and personal information to ensure they meet the high standards expected of VA healthcare providers. Additionally, the form inquires about professional references, licenses, and board certifications, verifying the applicant's capability to deliver competent and compassionate care to veterans. Filling out this form accurately is not only a requirement but a demonstration of the applicant’s attention to detail and commitment to serving those who have served. Understanding the intricacies and requirements of the VA 10-2850a form is crucial for anyone aiming to navigate the application process successfully and embark on a rewarding career within the Veterans Health Administration.
Approved Exception To SF 171
OMB No. 2900-0205
Use TAB key or Mouse to move between data fields Estimated burden: 30 minutes
Expiration Date: 3/31/2006
APPLICATION FOR NURSES AND NURSE ANESTHETISTS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs to determine your eligibility for appointment in Veterans Health Administration. Type, or print in ink. If additional space is required, please attach a separate sheet and refer to items being answered by number.
1. NAME (Last, First, Middle)
2. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
3. PRESENT ADDRESS (Street Address 1)
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
12E. TYPE OF DISCHARGE
HONORABLE
Other (Explain on separate sheet)
II - REGISTRATION AND
CLINICAL PRIVILEGES
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 NURSE ANESTHETIST BY THE COUNCIL ON CERTIFICATION OF NURSE ANESTHETISTS (CCNA)
YES NO
18B. WHAT IS THE DATE OF YOUR CERTIFICATION OR MOST RECENT RECERTIFICATION (GIVE MONTH AND YEAR)
18C. WHAT IS YOUR AMERICAN ASSOCIATION OF NURSE ANESTHETISTS (AANA) IDENTIFICATION NUMBER
18D. HAS YOUR CCNA CERTIFICATION EVER BEEN REVOKED
(If "YES" explain
on separate sheet)
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
JUL 2016
V - PROFESSIONAL LIABILITY INSURANCE
21A. PRESENT PROFESSIONAL LIABILITY INSURANCE CARRIER
21B. DATE COVERAGE BEGAN
21C. NAME OF PRIOR CARRIER
21D. DATES OF COVERAGE
FROM
TO
22.HAS ANY CARRIER EVER CANCELLED, DENIED OR REFUSED TO RENEW YOUR
INSURANCE
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.
CREDITS
24F.
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
26A. EMPLOYER
26B. ADDRESS (City, State and ZIP Code)
26C. POSITION
26D.
FULL TIME
26E.
PART-TIME
AVERAGE
HOURS PER
WEEK
26F. DATES EMPLOYED
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, I:
Authorize VA to make inquiries concerning such information about me to my previous employer(s), current employer, educational institutions, State licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to any other appropriate sources to whom VA may be referred by those contacted or deemed appropriate;
Authorize release of such information and copies of related records and/or documents to VA officials;
Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries; and
Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to make such inquiries.
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.
PAGE 4
After deciding to take a step forward in your career within the health services of the Veterans Administration (VA), you'll need to complete the VA 10-2850a form. This document is essential for anyone seeking positions such as physicians, dentists, nurses, and other healthcare professionals within the VA system. Filling out this form with accuracy and attention to detail is a critical step in the application process. It acts as your first impression and provides the VA with crucial information about your qualifications, experience, and suitability for the position you're applying for. Here are detailed steps to guide you through each part of the form, ensuring that your submission is as strong as it can be.
Once you’ve completed filling out the form and double-checked everything, follow the submission instructions specific to the job announcement or contact the VA office where you're applying to confirm their preferred method (mail, email, or hand delivery). Submitting this form is a significant step toward contributing to the healthcare of veterans, and ensuring its accuracy reflects your dedication and attention to detail. Good luck!
The VA 10-2850a form, also known as the "Application for Nurses and Nurse Anesthetists," is a document used by the Department of Veterans Affairs. It's designed for individuals applying for nursing positions, including nurse anesthetists within the VA healthcare system. This form is crucial for the evaluation of qualifications, certifications, and other relevant information pertinent to the nursing profession.
Any nursing professional, including registered nurses (RNs), nurse practitioners (NPs), and nurse anesthetists (CRNAs) who are seeking employment with the VA healthcare system must complete the VA 10-2850a form. It is a critical part of the application process to assess the eligibility and qualifications of the candidate for the desired nursing position.
The VA 10-2850a form requires detailed personal information, professional certifications, educational background, prior work experience, licensure specifics, and references. It also includes sections for self-disclosure about past employment and legal history. Additionally, the form asks for information related to any professional publications, research, memberships in professional organizations, and awards or recognitions in the field of nursing.
There are several ways to obtain the VA 10-2850a form:
The deadline for submitting the VA 10-2850a form may vary depending on the specific VA facility and the position applied for. Candidates are advised to check with the hiring department or the VA job listing for specific application deadlines. It is generally recommended to submit the form and any additional required documents well in advance of any stated deadlines to ensure timely consideration.
Yes, in many cases, the VA 10-2850a form can be submitted electronically. Applicants should verify with the specific VA facility where they are applying, as submission requirements can vary. Some locations may accept the form via email, while others might use an online application system. Always ensure to follow the given instructions for electronic submission to avoid any issues with your application.
After submitting the VA 10-2850a form, the following steps typically occur:
Assistance with completing the VA 10-2850a form can be found through several sources:
Filling out the VA 10-2850a form, which is necessary for those applying for health care positions within the Veterans Affairs system, requires careful attention to detail. Unfortunately, mistakes can occur during this process. Recognizing and avoiding these errors can streamline your application process and improve your chances of securing your desired position. Below are six common mistakes:
Avoiding these common mistakes can make the application process smoother and help your qualifications stand out more effectively. It's advisable to double-check your application before submission and ensure all necessary documents are attached. Such diligence can ultimately influence the success of your application.
When applying for health care positions within the Veterans Affairs (VA), the VA Form 10-2850a - Application for Nurses and Nurse Anesthetists is a crucial document. However, it's rarely submitted in isolation. Several other forms and documents often accompany it to complete a candidate's application package. These additional submissions help the VA to fully assess a candidate's qualifications, employment history, and suitability for a position. Understanding these documents can make the application process smoother and increase an applicant's chances of success.
To ensure a smooth application process to VA healthcare positions, candidates should carefully prepare and submit all required documents along with the VA Form 10-2850a. Each document serves a specific purpose, offering a fuller picture of the applicant's background, qualifications, and suitability for the role. Taking the time to gather and complete these documents thoroughly can greatly enhance an applicant's chances of being considered for employment.
Standard Form 86 (SF-86): Much like the VA 10-2850a, the SF-86 is a comprehensive document used in government processes. Specifically, the SF-86 is required for security clearance processes. Both forms gather detailed personal information, employment history, and references to verify the applicant's background and suitability for a position. However, while the VA 10-2850a is for healthcare professionals seeking VA employment, the SF-86 is broader, serving individuals applying for national security positions.
Form I-9, Employment Eligibility Verification: The Form I-9 is utilized by employers to verify an employee's identity and legal authorization to work in the United States. Similarly to the VA 10-2850a, which vets candidates for VA healthcare positions, the Form I-9 is a standard procedure for all newly hired employees. Both documents are part of the hiring process, emphasizing the verification of the candidate's qualifications and eligibility.
Application for Employment (Standard Form 171): This form is another parallel to the VA 10-2850a as it is also used in the hiring process, specifically by federal agencies prior to the adoption of more streamlined systems. Like the VA 10-2850a, the SF-171 collects comprehensive information on the applicant’s work history, education, and personal information to assess their suitability for federal employment.
Medical Examination Report Form for Commercial Driver Fitness Determination: This form, required for commercial drivers, shares a similarity with the VA 10-2850a in its focus on ensuring the health and fitness of the applicant for a specific role. While the VA form is geared towards healthcare professionals within the VA, this form is aimed at drivers to ensure they are physically capable of safely operating commercial vehicles. Both forms require a detailed health history and professional evaluation.
National Provider Identifier (NPI) Application/Update Form: The NPI form is critical for healthcare providers to obtain a unique identifier required for billing and identification across healthcare and insurance transactions. Like the VA 10-2850a, it is specific to healthcare professionals. Both forms are integral to the professional validation and operational processes within the healthcare system, albeit serving different administrative functions.
Filling out the VA 10-2850a form, an application for Nurses and Nurse Anesthetists, requires careful attention to detail. This document is critical in the employment process for professionals seeking to work within the VA healthcare system. Below are lists of recommended actions to ensure the form is completed accurately and thoroughly.
Do:
Don't:
The VA 10-2850a form is an application widely recognized within the medical community for those seeking employment within the Veterans Health Administration. Like many government forms, it is surrounded by various misconceptions that can create confusion. Clarifying these misconceptions is crucial to ensure that potential applicants have a clear understanding of its purpose and requirements.
While it's true that the VA 10-2850a form is often associated with physicians, it's actually required for multiple types of healthcare professionals seeking positions at the VA. This includes not just physicians, but also dentists, podiatrists, optometrists, and chiropractors. The form helps the VA assess qualifications and suitability for healthcare roles beyond just medical doctors.
Submission of the VA 10-2850a form is merely the initial step in the application process. Although submitting this form is necessary, it does not guarantee an applicant will be called for an interview. Employment at the VA is highly competitive, and many factors, including experience, specific qualifications, and the needs of the facility, play a role in who gets offered an interview.
While the primary use of the information on the form is indeed for employment evaluation, it serves dual purposes. The data collected can also be used for background checks and ensuring that applicants meet all legal and professional standards necessary for working within the federal system. This comprehensive use underscores the importance of accuracy and honesty in completing the form.
Circumstances change, and so do the details of one’s professional life. If significant changes occur between the time of submission and hiring, such as obtaining new licenses, certifications, or facing disciplinary actions, it's essential to update the form. Keeping your application current is crucial, as it ensures the VA has the most accurate information to make informed decisions.
The VA 10-2850a form, an application for employment in the Veterans Health Administration, is a critical step for healthcare professionals seeking to join this federally run service. The form serves multiple purposes, from background checks to credential verification. Successfully navigating the intricacies of this form can significantly streamline the application process. Here are four key takeaways for filling out and using the VA 10-2850a form effectively:
Adhering to these guidelines will not only demonstrate a candidate's attention to detail and seriousness about the application but also facilitate a smoother transition through the VA's employment process. Remember, the VA 10-2850a form is often the first impression you make on your potential employer, making it imperative to approach it with diligence and care.
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