The VA 10-2850c form is a crucial document for healthcare professionals looking to apply for positions within the Veterans Health Administration. It serves as an application for employment, asking for detailed information that assesses the applicant’s qualifications, background, and abilities. To streamline your application process and join the team dedicated to serving our veterans, click the button below to fill out your form.
In the landscape of employment within the United States Department of Veterans Affairs (VA), prospective candidates are often required to navigate the complexities of various forms and documents, one of which is the VA 10-2850c form. This specific form serves as a pivotal piece in the application process for those seeking positions within the VA's healthcare sector, particularly roles that involve providing clinical services to veterans. It collects detailed information on the applicant’s professional credentials, educational background, previous employment history, and personal data to assess their eligibility and fitness for the position in question. Furthermore, the VA 10-2850c form includes sections dedicated to licensure information, certifications, and references, all of which are crucial for a thorough review by hiring officials. Designed to streamline the hiring process while ensuring that only the most qualified individuals are considered, this form plays a critical role in maintaining the high standards of care provided to our nation's veterans. By delving into the major aspects of the VA 10-2850c form, individuals can better understand its significance in the application process and prepare themselves effectively for a career within the VA.
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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
When you're ready to take a significant step towards working with veterans by applying for a healthcare position at the Veterans Affairs (VA), filling out the VA Form 10-2850c is a crucial step. This form is your opportunity to present your qualifications, background, and suitability for the role you're applying for. Completing it accurately and comprehensively is critical to proceed with your application. The process might seem daunting at first, but breaking it down into steps can make it manageable and straightforward. Here are the steps you need to follow to fill out the VA Form 10-2850c correctly.
Once you've submitted your VA Form 10-2850c, the next steps involve waiting for the VA to process your application. This may include verification of your credentials, background checks, and possibly interviews. Throughout this time, it's important to be patient and remain available for any additional information requests or interview calls. Successfully submitting this form is a significant step towards a fulfilling career supporting veterans, so take a moment to appreciate your effort in completing it diligently.
The VA 10-2850c form, also known as the "Application for Associated Health Occupations," is a document used by the Department of Veterans Affairs (VA). It's designed for individuals applying for various associated health positions within the VA, such as nurses, pharmacists, and other health care professionals. This form is required to assess qualifications and suitability for the desired position.
Any individual applying for employment in associated health occupations at the VA should complete this form. It's specifically tailored for those seeking positions like nurse practitioners, physical therapists, occupational therapists, and more. Ensuring you fall within the required categories before filling out this form is essential.
Typically, you should submit the VA 10-2850c form at the time of your application for a position. However, the exact timing can vary based on the specific job posting and the VA facility's requirements. It's advisable to check the job listing or contact the HR department of the VA facility where you're applying to confirm the submission deadline.
You will need to share a variety of information on the form, including but not limited to:
The submission process can vary by location and specific job opportunity. In general, you may submit this form electronically via the VA career website or mail it directly to the relevant VA facility. Always confirm the preferred submission method by checking the job posting or contacting the facility's HR department.
No, there is no fee to file the VA 10-2850c form. The Department of Veterans Affairs does not require a filing fee for job applications, including this form.
After submission, your form will be reviewed as part of the broader application process. You may be contacted for additional information or to schedule an interview. Given the competitive nature of positions at the VA, the review process can take some time. Patience and attentiveness to any follow-up requirements will be beneficial.
Generally, once submitted, you cannot make changes to the form directly. If you need to update or correct information, it's best to contact the VA facility's HR department or the hiring manager as soon as possible. They can guide you on the best course of action for making any necessary adjustments to your application.
For assistance with the VA 10-2850c form, consider the following resources:
Filling out the VA 10-2850c form, which is required for healthcare professionals seeking to practice or affiliate with the Department of Veterans Affairs, is a crucial step that demands careful attention to detail. However, individuals often make errors during this process that can delay or negatively impact their application. The following list elaborates on common missteps encountered:
Omitting Required Information: Applicants sometimes leave sections blank, not realizing that every question is designed to assess their qualifications and background comprehensively. Failure to provide necessary details can result in the application being returned or delayed.
Incorrect Details: Providing inaccurate information, whether unintentionally (typographical errors) or intentionally (misrepresentations), can have serious consequences. Verification processes are thorough, and discrepancies are likely to be discovered.
Not Following Instructions for Supporting Documents: The form often requires supplementary documents (e.g., licenses, certifications). Neglecting to attach these, or submitting incorrect or outdated documents, can hinder the application process.
Using an Outdated Form Version: The VA periodically updates its forms, including the 10-2850c, to reflect current regulations and requirements. Utilizing an outdated version could mean submitting incomplete or incorrect information based on the form's requirements at the time.
Illegible Handwriting: When the form is filled out by hand, poor handwriting can lead to misunderstandings or the need for clarification, thereby stalling the application's review. Wherever possible, typing the information is preferred.
Failure to Sign and Date the Form: An unsigned or undated application is considered incomplete. This simple oversight can invalidate the entire submission, necessitating the applicant to resubmit, thus extending the waiting period.
Not Retaining a Copy: Applicants often forget to keep a copy of their submitted form for their records. This oversight can become problematic if there are queries or if the original submission is misplaced. Having a copy ensures the applicant has a reference and can provide follow-up documentation consistent with the initial submission.
Correctly completing the VA 10-2850c is integral to a successful application to the Department of Veterans Affairs. Applicants are encouraged to review their application thoroughly, adhere to the guidelines provided, and ensure all information is complete and accurate before submission. Addressing these common mistakes can streamline the process, helping applicants avoid unnecessary delays.
Navigating the landscape of documentation required for various processes within the Veterans Affairs (VA) can seem daunting at first. Among these documents, the VA Form 10-2850c stands out as a crucial form for healthcare professionals seeking employment within the VA system. However, this form rarely travels alone. To ensure a comprehensive and successful application or submission, several other forms and documents are often positioned alongside the VA 10-2850c. Below is a curated list of other forms and documents typically used in conjunction with the VA 10-2850c, each serving its unique purpose in the broader context of an individual's application or professional journey within the VA system.
While each document serves its purpose, together they comprise the backbone of a comprehensive application, ensuring that candidates are thoroughly vetted and considered for roles within the VA. Whether you're a seasoned professional in healthcare looking to contribute to the welfare of veterans or a new applicant aspiring to join the VA, understanding and preparing these documents in advance can significantly smooth the path towards employment. Remember, each form or document you submit helps to paint a fuller picture of your professional profile, aspirations, and the value you can bring to the Veterans Affairs healthcare system.
The VA 10-2850c form, used primarily for healthcare professionals seeking employment within the Veterans Health Administration, shares similarities with various other forms in terms of function, purpose, and sometimes structure. Below is a list of 10 documents that bear resemblance to the VA 10-2850c form:
These documents, while tailored to specific purposes or sectors within the professional and healthcare fields, share the common goal with the VA 10-2850c form of accurately collecting detailed information to assess an applicant's eligibility and qualifications for a position.
The VA 10-2850c form is critical for professionals seeking to provide healthcare services within the Department of Veterans Affairs. Ensuring accuracy and completeness when filling out this form is paramount. Here are some do's and don'ts to consider:
When it comes to employment within the Veterans Affairs (VA) health system, the VA Form 10-2850c - Application for Associated Health Occupations - is a crucial document. However, misconceptions about this form are prevalent, often leading to confusion and errors in the application process. Let's clear up some of these misunderstandings:
While it's true that the form is designed for associated health occupations (such as nurses, pharmacists, and therapists), it's not exclusively for those with a medical background. Administrative roles directly impacting patient care also require this form, emphasizing the VA's comprehensive approach to patient-centric care.
Contrary to this belief, updating the VA Form 10-2850c may be necessary, especially if any significant changes in your employment history, certifications, or personal information occur. Keeping your form updated ensures your qualifications are accurately reflected at all times.
Although detailed, completing the VA Form 10-2850c is straightforward once you understand what's required. The form is designed to collect comprehensive information in a structured manner, ensuring all applicants are evaluated fairly based on their qualifications and experiences.
While filling out the form is a necessary step in the application process, it does not guarantee employment. The VA considers numerous factors during hiring decisions, including qualifications, experience, and the needs of the facility. Consider the form as one of the first steps in showcasing your ability to contribute to veterans' care.
This is a common error. Every section of the VA Form 10-2850c, including personal information, is crucial. This comprehensive approach assists in maintaining a safe and secure environment for veterans and staff by verifying the identity and background of applicants.
Even if you are moving or transferring to a different VA facility, completing a new VA Form 10-2850c might be required. Transfers can involve changes in roles, responsibilities, or departments, meaning reevaluation based on current qualifications and experience is often necessary.
The VA 10-2850c form, known as the "Application for Associated Health Occupations," is an essential document for individuals seeking employment in various health care positions within the Veterans Health Administration (VHA). Understanding how to properly fill out and utilize this form is crucial for applicants. Here are key takeaways to guide you through this process:
Following these guidelines when completing the VA 10-2850c form will help streamline the application process and improve your chances of securing a position within the Veterans Health Administration.
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