The VA 10-2850a form is an essential document used by healthcare professionals who wish to apply for a position within the Department of Veterans Affairs. This form serves to gather personal and professional information necessary for employment consideration. Understanding its requirements can streamline your application process and enhance your chances of securing a position.
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The VA 10-2850a form plays a crucial role in the process of applying for employment within the Veterans Affairs (VA) healthcare system. This application form is specifically tailored for nurses, nurse practitioners, and nursing assistants seeking to join the workforce that serves our veterans. It's designed to collect comprehensive information about the applicant’s education, clinical skills, and work experience, ensuring that the VA can assess the qualifications of potential candidates accurately. Additionally, the form seeks to gather pertinent biographical data and professional licenses, which are essential for verifying credentials in the highly regulated field of healthcare. Completing the VA 10-2850a accurately is vital, as it influences the hiring process, giving applicants an opportunity to showcase their unique qualifications and experiences. Whether one is a seasoned professional or a new graduate, understanding the nuances of this form can lead to a smoother application experience, ultimately benefiting those who dedicate their careers to providing care for our nation's heroes.
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.
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Completing the VA 10-2850a form is an important step for those seeking employment or opportunities with the Department of Veterans Affairs. It is essential to provide accurate and comprehensive information to ensure that your application is successful. Follow the steps below carefully to fill out the form properly.
By following these steps diligently, you can ensure that your VA 10-2850a form is filled out correctly and submitted in a timely manner. Take your time, and remember that thoroughness can make a significant difference.
The VA 10-2850a form is used by individuals seeking appointment in the Veterans Health Administration (VHA). This form collects essential information about your education, experience, and qualifications to ensure that you meet the requirements for employment within the VA system.
This form is typically required for healthcare professionals, including physicians, nurses, and allied health staff who wish to work for the VA. If you are applying for a position that involves patient care or treatment, you will likely need to complete this form.
You can find the VA 10-2850a form on the official U.S. Department of Veterans Affairs website. The form is available as a downloadable PDF, which you can print and fill out. Ensure that you have the latest version, as forms may be updated periodically.
The form requires personal information, including your name, contact information, and Social Security number. You will also need to provide details about your education, licensure, and work experience, particularly in healthcare settings.
While there is no specific deadline for submitting the form, it is recommended that you complete and submit it as soon as possible when applying for a position. Delay in submission can impact your overall application timeline.
If you realize that you have made an error after submitting the form, contact the human resources department of the VA facility to which you applied. They can provide guidance on how to correct the mistake and ensure your application is processed accurately.
Submitting the VA 10-2850a form online depends on the specific VA facility’s application process. Some locations may allow electronic submission, while others require a printed version. Verify the submission process with the facility’s HR department.
After submission, your application and form will be reviewed by the hiring officials. They will assess your qualifications and background in relation to the position for which you applied. You may be contacted for an interview or asked to provide additional documentation.
No, there is no fee to complete or submit the VA 10-2850a form. It is a free form provided by the U.S. Department of Veterans Affairs for individuals seeking employment within the VA system.
When completing the VA 10-2850a form, many individuals often overlook important details that can affect their application process. One common mistake is not providing complete contact information. It's crucial to include a valid address, phone number, and email. Omitting any of these details can result in delays or missed communications from the VA.
Another frequent error involves the failure to sign and date the form. Without a signature, the application may be considered incomplete, which could lead to denial. Additionally, some individuals rush through the process and may forget to date the form altogether, further complicating their submission.
Inaccuracies in providing professional experience can lead to complications as well. Some applicants fail to list all relevant work history or misrepresent their roles. Ensuring that the information is both accurate and comprehensive is vital for a successful application.
Furthermore, neglecting to include all necessary supporting documentation is a significant mistake. The VA may require specific documents to process the application accurately. Those who do not provide these documents may face unnecessary delays in their application being reviewed.
Another pitfall is submitting the form without reviewing it for errors. Simple mistakes, such as misspelled names or incorrect Social Security numbers, may seem minor but can have serious implications. A thorough review can help catch these errors before submission.
Lastly, many individuals do not follow the specific instructions outlined for the form. Each section has particular requirements, and failing to adhere to these can result in complications. It's important to understand the instructions completely to ensure that the form is filled out correctly.
The VA 10-2850a form, used for applying for a position in the Veterans Health Administration, often requires several additional documents to provide a comprehensive application package. These documents support various aspects of your qualifications and background and can significantly enhance your application. Below is a list of relevant forms and documents that can accompany the VA 10-2850a.
Incorporating these documents alongside the VA 10-2850a will create a more robust application, demonstrating your preparedness and commitment to the position you are seeking. Ensure all items are current and aligned with the application’s requirements to enhance your chances of success.
The VA Form 10-2850a, also known as the Application for Nurses and Nurse Anesthetists, is a crucial document used by individuals applying for nursing positions within the Department of Veterans Affairs (VA). While it serves a specific purpose, there are other documents that share similarities with it. Here’s a list of four such documents, highlighting their respective similarities:
Each of these forms is crucial for the respective application processes within the VA, and they similarly aim to gather comprehensive information about the candidates to ensure that only qualified professionals are considered for employment or scholarships.
When filling out the VA 10-2850a form, here are key points to consider. Proper preparation can lead to a smoother application process. Below is a list of what you should and shouldn't do:
By following these guidelines, applicants can help ensure their forms are processed efficiently. Accuracy and thoroughness are vital for a successful submission.
There are several misconceptions surrounding the VA 10-2850a form that could lead to confusion for veterans and healthcare providers alike. Understanding the truth behind these misconceptions is crucial for proper completion and submission of the form.
Awareness of these misconceptions can help ensure a smoother experience with the VA 10-2850a form. Always review the requirements thoroughly to avoid unnecessary setbacks.
The VA 10-2850a form is an important document for health care professionals seeking employment with the Department of Veterans Affairs. Here are some key takeaways to consider while filling out and using this form:
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