Privacy Act notice
The information is voluntary and solicited under 5 U.S.C. 3302 as promulgated by E.O. 10577, Rule VII, Section 7.1. The notice says that without it, it may not be possible to evaluate qualifications fully.
4676a
Employee Supplemental Qualifications Statement
- Agency
- VA
- Revision
- September 1992
- Fillable fields
- 11
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 4676a: Employee Supplemental Qualifications Statement
VA Form 4676a is the U.S. Department of Veterans Affairs Employee Supplemental Qualifications Statement. It is a personnel form for a specific VA position: the form says it will be the primary source document used to evaluate the candidate's qualifications and to rate and rank them for that position. It is not a benefits form, and VA's form page lists it under VACO.
The Personnel Office lists the rating factors for the job on the form, the knowledge, skills, abilities or other characteristics (KSAO's) or job elements, and the candidate describes the experience, education, training, awards and other activities that show each one. The PDF is three pages: identification and instructions, then two continuation pages for the responses, each with a certification and signature. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 4676a
Identification
Name, present position (title, grade, division/service), position applied for (title and grade) and the announcement number.
Note and instructions
The candidate instructions ask that each response name the supporting document (such as an SF 171, award or performance requirement), where it is kept (such as the official Personnel Folder) and the past activity or employment behind it.
Rating factors and responses
Space for the rating factors and the applicant's response on page 1, continued on pages 2 and 3.
Certification and signature
The applicant certifies the statements are true, complete and correct and subject to verification, and that intentional misstatements or falsification may result in disciplinary action, then signs and dates.
How to fill out VA Form 4676a
- 1
Get the rating factors
Personnel lists the rating factors or job elements on the form. The form says additional guidance in completing it is available from the Personnel Office, upon request.
- 2
Fill in your details
Enter your name, present position, the position applied for and the announcement number.
- 3
Answer each rating factor
Describe in detail the experience, education, training, awards and other activities that show each factor, and with each response name the document, where it is kept and the past activity or employment that supports it.
- 4
Use the continuation pages
If more space is needed, the form says to use the attached blank pages, which continue the rating factors and responses.
- 5
Review, sign and date
The form says to read it over carefully, make sure all items are completed and your name is on all pages, then sign and date the certification.
Why fill Form 4676a on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and getting help
Where it goes
The form is used for a specific VA position and prints no mailing address, fax number or online option. It points to the Personnel Office for guidance.
Verification
The certification says the statements are subject to verification and that the candidate agrees to furnish supporting documents or information when requested.
Edition
Page 1 is marked VA FORM SEP 1992 (R) 4676a, and pages 2 and 3 VA FORM 4676a, SEPTEMBER 1992. VA's form page lists a revision date of September 1992.
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Who uses VA Form 4676a?
The form gives separate instructions to the candidate and to Personnel.
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Questions about Form 4676a
What is VA Form 4676a used for?
The form says it is the primary source document used to evaluate a candidate's qualifications and to rate and rank them for a specific VA position.
Is VA Form 4676a a benefits form?
No. It is a personnel form for VA jobs. VA's form page lists it under VACO, and the form addresses a candidate and the Personnel Office.
Who lists the rating factors?
The Personnel instructions say the form may be used for VA jobs by listing the specific rating factors or job elements, and how each one should be answered.
Is giving the information required?
The Privacy Act notice says the information requested is voluntary, and that if you decline to provide it, it may not be possible to evaluate your qualifications fully.
What should each response include?
The candidate instructions ask for the supporting document, its location, such as the official Personnel Folder (OPF), and the past activity or employment that supports the response.
What if I need more space?
The form says to use the blank pages attached. Pages 2 and 3 continue the rating factors and applicant's response.