10-2850d
Application for Health Professions Trainees
VA Form 10-2850D is the U.S. Department of Veterans Affairs Application for Health Professions Trainees, listed on VA's page under employment or jobs at VA. The PDF itself is titled Health Professions Trainee Data Collection Form. Its instructions ask for all information in enough detail to enable VA to determine the applicant's eligibility for appointment, and the Privacy Act notice says the information is collected to determine qualifications and suitability for appointment to a VA clinical training program.
The form is four pages. The trainee fills in identification, military duty status, citizenship, licenses, education, internship and residency training, additional questions, remarks and a certification, then signs an Authorization for Release of Information. Section IV is completed by the facility's Designated Education Officer (DEO) or designee. It is a VA training appointment form, not a benefits form a Veteran files.
The form says clinical training programs may require additional information from trainees. You can fill out the PDF free in your browser on this page and download the result without an account.
Name and other names used, address, phone numbers, Social Security number, email addresses, date of birth, VA training facility and dates, past VA or federal employment including DoD, military, Reserves or National Guard status, branch of service, citizenship and place of birth.
Yes or no items on the TQCVL criteria and on incomplete items being resolved, special attention items, comments, Medical Center Director approval, and the DEO or designee's signature, title and date.
Every license, certification and registration in the current and any previous clinical profession, including DEA, with issuing state, number and expiration date, the National Provider Identifier, and two questions on actions against a license or clinical privileges.
Schools after high school through graduate or professional school, international medical school graduation and ECFMG certificate, and internship, residency and fellowship training with specialty, dates and months completed.
Yes or no questions on false statements in the Medicare and Medicaid programs and on malpractice proceedings, with details of any yes answer written in the Section XI remarks by item number.
The trainee's certification and signature, then an Authorization for Release of Information that lets VA make inquiries of employers, schools, licensing boards and other sources, with a second signature and date.
The instructions say to type or print in ink and, if more space is needed, to attach a separate sheet that refers to the items being answered by number.
Complete Sections I to III and V to XI. Items 10A to 10D are only for applicants who are not U.S. citizens.
Items 16, 17, 21 and 22 say to explain a yes answer in Section XI, and the remarks section says to indicate the item number each comment refers to.
Sign and date Items 23A and 23B, then sign and date the Authorization for Release of Information below it.
The Designated Education Officer or designee completes Section IV, including whether the Medical Center Director approved the trainee for appointment, and signs Item 12A.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form prints no mailing address for applications. The Paperwork Reduction Act notice gives VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC 20420 for burden comments and says do not send applications to this address.
The instructions say clinical training programs may require additional information from trainees, and that all information required by the training program, as well as information requested on all data collection forms, must be included.
The notice estimates an average of 30 minutes to complete the form. It carries OMB Control No. 2900-0205.
AUG 2024, matching the August 2024 revision date on VA's form page.
10-0376a
83 fields, 2 pages
10-0459
5 fields, 1 page
10-9055
29 fields, 8 pages
10-9054
29 fields, 8 pages
10-0102
47 fields, 2 pages
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Health professions trainees applying for a VA clinical training appointment complete the applicant sections and sign it. Section IV is completed by the Designated Education Officer (DEO) or designee.
The Privacy Act notice says completion of this form is mandatory for consideration of an application for a clinical training position in VA. A separate notice says disclosure of the Social Security Number is mandatory to obtain the employment and benefits sought.
The note in Section III says to complete Items 10A, 10B, 10C or 10D only if you are not a U.S. citizen. They cover immigrant, exchange visitor and other non-immigrant visa details and Form DS2019.
Section IV refers to the Trainee Qualifications & Credentials Verification Letter. The DEO or designee records whether the trainee met all of its criteria and whether incomplete items were addressed and resolved.
It authorizes VA to make lawful inquiries of current and previous employers, educational institutions, state licensing boards, professional liability insurance carriers and references, and to share information with the affiliated institution or training program official.
Item 22 asks for details in Section XI, including the name of the action or proceedings, date filed, court or reviewing agency, and status or outcome. The form says any conclusion will be made only after a full evaluation of the circumstances involved.
