VA RESIDENT PROCESSING

2016 CHECKLIST Missing or incomplete documents will delay your rotation to Hines VA Hospital

Dr. _____________________________________________ PGY Level ____________ Please Print

Program___________________________________ Previous VA work experience _________

REQUIRED DOCUMENTS FOR ALL RESIDENTS

CITIZENSHIP VERIFICATION (Please answer the following questions)

Health Trainees Application (VA form 10-2850D) (complete/sign; copy must be provided to Human

Resources, Bldg.17, Hines VA Hospital)

Security Alert Regarding Fingerprinting

Declaration of Federal Employment Application (OF306) (complete/sign; copy must be provided to Human Resources, Bldg.17, Hines VA Hospital)

SAC Form: Fingerprinting done at Human Resources, Bldg. 17, Hines VA Hospital (no more than 45 days in advance). Bring your driver’s license and your social security card to verify social security number.

2 copies included- one to HR when you get fingerprinted and one to be included in the completed packet. Please inform HR/VA Representative if and when fingerprints were completed if done at a different VA outside of Hines VA Hospital.)

Appointment Affidavit (VA Form 61) (sign) (DOES NOT NEED TO BE NOTARIZED)

Clinical Registration Memorandum (Needed for Hines Computerized Patient Records Systems access)

Laptop Agreement Form (Remote access to Hines Network)

Certificate of completion of Trainee Online Mandatory Training (Required course: Training takes approximately one hour to complete. Can be accessed at www.tms.va.gov from any Internet connection.)

Complete CPRS Training Modules (Hines VA Hospital Informatics will contact via email)

E-QIP processing (After fingerprinting HR assigns the email link to complete, print out the two designated signature pages (CER & REL) for Background Investigation (Only 96 hours to complete after initiation if required).

Born in the United States? YES NO

Naturalized Citizen? If yes, copy of certification is attached. YES NO/NA

Non-US Citizen? If yes, copy of passport is attached. YES NO/NA

If yes, attach copy of valid J-1 visa (DS 2019) or YES NO/NA

Copy of Alien registration card. YES NO/NA

Foreign Medical School graduate? If yes, copy of ECFMG

certification is attached. YES NO/NA

VA Application Packet FAQ

The purpose of this document is to answer some of the frequently asked questions about the paperwork required for the VA

application.

Required paperwork:

o Health Trainees Application (10-2850d)

o Declaration of Federal Employment (OF306)

o SAC Form

o Appointment Affidavit (SF61)

o Clinical Registration Form

o Laptop Agreement Form

o Fingerprints

o Complete CPRS Training Modules

o Certificate of Completion of Mandatory

Training for Trainees Online course accessed via

TMS

Frequently missed or asked information for required forms:

Health Trainees Application (10-2850d): Be sure to fill out completely. There are two signatures required on

this form. In addition, please complete your education history as completely as possible. If there are gaps of

over one year, please attach an additional page with a brief explanation of what you were doing during that

time (i.e. studying for exams; traveling; working in research; etc.).

SAC Forms: Please be sure to include one completed copy in your application packet. When you get

fingerprinted at HR at Hines or another VA facility, the HR department requires a copy of the SAC form to

complete the fingerprinting. Please be aware of this requirement and ensure that there is an additional copy of the

SAC form in your application packet that is submitted to Hines.

Appointment Affidavit (SF61): Please complete and sign the form. This form does NOT need to be notarized.

Clinical Registration Form: Please fill out this form completely, including indicating whether you have obtained

a DO or an MD.

Laptop Agreement Form: This needs to be signed for remote access to be granted.

Fingerprinting: Please be aware that your fingerprints are only valid for 120 days. If you get fingerprinted too

soon, you will have to get re-printed in order to obtain your PIV card. However, you cannot wait too long to get

fingerprinted either as that will delay the background check process which will delay your start. The ideal time

to get fingerprinted at the Hines VA would be no more than 45 days before your start date though you can

be fingerprinted at any VA facility nationwide. Bring your driver’s license and your social security card. If

you decide to get fingerprinted somewhere other than Hines VA, it is imperative that you notify your VA

coordinator and inform them of when and where you were fingerprinted. This will make the background check

portion move more quickly and eliminate delays in processing. If you get fingerprinted at another VA facility you

will need to give them the following numbers:

SOI: VAA7; SON: 1255; OPAC: 3600 1200

CPRS training: A link will be sent to you in a welcome letter from Hines Informatics. This is a required training

that will prepare you for an in-person competency examination that is typically scheduled during VA orientation.

If you do not get this competency exam scheduled, please contact your VA coordinator.

TMS training: Self-register at www.tms.va.gov and complete Mandatory Training for Trainees (VA 3185966).

This is a yearly requirement to continue to have computer access at the VA. After year 1, you are required to

complete the refresher course (Mandatory Training for Trainees-Refresher (VA 3192008)). This should be the

only TMS course you are required to take. TMS training must be completed at least 3 weeks prior to your

start date to give time to create computer accounts. If not completed at least 3 weeks prior to your start date,

this could cause a delay in your start. TMS can be accessed from any computer with Internet access. It does

not need to be completed at the VA.

Be sure to fill out each form completely. Any incomplete forms will delay the processing of your paperwork.

Additional paperwork that MAY be required:

o EQIP Processing

o Copy of J1 Visa

o Copy of Alien Registration Card

o ECFMG Certificate

o Copy of Naturalization Certificate

o Copy of Passport

Citizenship Verification:

Were you born in the U.S.? If yes, no citizenship verification materials are needed. If you are not a US citizen, a

copy of your valid J-1 Visa (Valid DS2019) or Alien Registration Card is required. Non-citizens are also required

to submit a copy of their passport.

Are you a naturalized citizen? If yes, a copy of your naturalization certificate is required.

Medical School Verification:

Did you attend a foreign medical school? If yes, a copy of your ECFMG certificate is required. If no, no

documentation is required for the VA.

EQIP Processing: If you are required to complete EQIP, an HR representative will contact you using the contact

information provided on the Health Trainees Application. It is very important that this be completed accurately and

efficiently. Once EQIP is initiated, you have 96 hours to complete the form. Not everyone will be required to complete

EQIP. This is based on the program and the time spent at the VA. An HR representative will notify you if EQIP is

required, so please watch your email and voicemail for this message.

If there are additional questions beyond what is covered here, please email your VA

coordinator or contact me directly at erin.karpus@va.gov.

TMS training: Self-register at www.tms.va.gov and complete Mandatory Training for Trainees (VA 3185966).

This is a yearly requirement to continue to have computer access at the VA. After year 1, you are required to

complete the refresher course (Mandatory Training for Trainees-Refresher (VA 3192008)). This should be the

only TMS course you are required to take. TMS training must be completed at least 3 weeks prior to your

start date to give time to create computer accounts. If not completed at least 3 weeks prior to your start date,

this could cause a delay in your start. TMS can be accessed from any computer with Internet access. It does

not need to be completed at the VA.

Be sure to fill out each form completely. Any incomplete forms will delay the processing of your paperwork.

Additional paperwork that MAY be required:

o EQIP Processing

o Copy of J1 Visa

o Copy of Alien Registration Card

o ECFMG Certificate

o Copy of Naturalization Certificate

o Copy of Passport

Citizenship Verification:

Were you born in the U.S.? If yes, no citizenship verification materials are needed. If you are not a US citizen, a

copy of your valid J-1 Visa (Valid DS2019) or Alien Registration Card is required. Non-citizens are also required

to submit a copy of their passport.

Are you a naturalized citizen? If yes, a copy of your naturalization certificate is required.

Medical School Verification:

Did you attend a foreign medical school? If yes, a copy of your ECFMG certificate is required. If no, no

documentation is required for the VA.

EQIP Processing: If you are required to complete EQIP, an HR representative will contact you using the contact

information provided on the Health Trainees Application. It is very important that this be completed accurately and

efficiently. Once EQIP is initiated, you have 96 hours to complete the form. Not everyone will be required to complete

EQIP. This is based on the program and the time spent at the VA. An HR representative will notify you if EQIP is

required, so please watch your email and voicemail for this message.

If there are additional questions beyond what is covered here, please email your VA

coordinator or contact me directly at erin.karpus@va.gov.

VA FORM 10-2850DNOV 2011

11E. This applicant has been approved for appointment.

INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans Affairs (VA) to determine your eligibility for appointment. Type or print in ink. If additional space is needed, please attach a separate sheet and refer to items being answered by number. Applications for clinical training programs may require additional information. All information required by the training program to which you are applying, as well as information requested on all application forms, must be included.

VA must protect the safety of our patients. Therefore, at some point in the appointment process, you will be asked questions about your physical and mental health. This includes questions as to whether you have received tuberculin testing, hepatitis B vaccinations or any other vaccinations.

II - U.S. MILITARY DUTY STATUS

III - CITIZENSHIP

IV- THIS SECTION TO BE COMPLETED BY DESIGNATED EDUCATION OFFICER (DEO) OR DESIGNEE

11A. The trainee has met all of the criteria of the Trainee Qualifications & Credentials Verification Letter (TQCVL).

PAGE 1 OF 4

7C. VA TRAINING END DATE (mm/yyyy)

SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER

OMB Number: 2900-0205Estimated Burden: 30 minutes

APPLICATION FOR HEALTH PROFESSIONS TRAINEES

7B. VA TRAINING START DATE (mm/yyyy)

10A. IMMIGRANT 10B. EXCHANGE VISITOR

9A. CITIZENSHIP

NOTE: Complete items 10A, 10B, 10C, or 10D ONLY if you are NOT a U.S. citizen.

10C. OTHER NON-IMMIGRANT 10D. FORM DS2019

DO YOU HAVE A VALID DS2019?

12B. TITLE12A. SIGNATURE OF FACILITY DESIGNATED EDUCATION OFFICER OR DESIGNEE 12C. DATE

11B. Incomplete items on the TQCVL have been addressed and resolved.

8A. ARE YOU NOW IN U.S. MILITARY?

1A. NAME (Last, First, Middle)

2. PRESENT ADDRESS (Include ZIP Code) 3A - PRIMARY PHONE (Include area code)

3B - ALTERNATE PHONE (Include area code)

5A. PRIMARY EMAIL ADDRESS 6. DATE OF BIRTH (mm/dd/yyyy)4. SOCIAL SECURITY NUMBER

UNKNOWN

YES NO

8C. BRANCH OF SERVICE

U.S. CITIZEN BY BIRTH NATURALIZED U.S. CITIZEN NOT A U.S. CITIZEN (Complete item 9B)

9B. COUNTRY OF CITIZENSHIP

"A" NUMBER

DATE

VISA TYPE VISA NUMBER

ISSUE DATE EXPIRATION DATE

VISA NUMBERVISA TYPE

ISSUE DATE EXPIRATION DATE

YES NO

DATE OF LAST VALIDATION (MM/DD/YYYY)

11C. Special attention has been given to the following items from the application forms.

YES NO

YES NO

(If YES, complete 8c)

NO YES

7A. VA TRAINING FACILITY (City, State)

UNKNOWN

11F. Comments:

1B. OTHER NAMES USED

8B. ARE YOU IN THE RESERVES OR NATIONAL GUARD?

YES NO(If YES, complete 8c)

5B. ALTERNATE EMAIL ADDRESS

11D. Comments:

VA FORM 10-2850DNOV 2011

VII - EDUCATION AND TRAINING AFTER HIGH SCHOOL THROUGH GRADUATE / PROFESSIONAL SCHOOL (Continue in Part XI if necessary)

IX- INTERNSHIP, RESIDENCY AND FELLOWSHIP TRAINING

VIII - GRADUATES OF AN INTERNATIONAL MEDICAL SCHOOL

VI- LICENSE, CERTIFICATION, OR REGISTRATION IN OTHER/PREVIOUS CLINICAL PROFESSION(S)

18F. MAJOR FIELD OF STUDY

V- LICENSE, CERTIFICATION, OR REGISTRATION IN CURRENT CLINICAL PROFESSION

PAGE 2 OF 4

20F. NUMBER OF

MONTHS COMPLETED

20B. ADDRESS (City, State and ZIP Code) 20C. SPECIALTY20E.(EXPECTED)

COMPLETION DATE (MM/YY)

18A. NAME OF SCHOOL 18B. ADDRESS (City, State, and Zip Code)18C. START

DATE (MM/YY)

18D. (EXPECTED) COMPLETION DATE (MM/YY)

18E.DIPLOMA, DEGREE, OR CERTIFICATE AWARDED OR IN

PROGRESS

19A. ARE YOU A GRADUATE OF AN INTERNATIONAL MEDICAL SCHOOL?

13C. LICENSE, CERTIFICATION OR REGISTRATION NUMBER

13D. EXPIRATION DATE

(MM/DD/YYYY)

13A. LIST ALL LICENSES, CERTIFICATIONS,AND REGISTRATIONS, INCLUDING THE DRUG ENFORCEMENT AGENCY (DEA), THAT YOU HAVE NOW OR HAVE HAD AS A HEALTH PROFESSIONAL, I.E. MEDICAL, NURSING, PHARMACY, ETC.

16. DO YOU HAVE PENDING, OR HAVE YOU EVER HAD ANY LICENSE, CERTIFICATION, OR REGISTRATION TO PRACTICE (INCLUDING DEA CERTIFICATE) REVOKED, SUSPENDED, DENIED, RESTRICTED, OR PLACED ON A PROBATIONARY STATUS, OR HAVE YOU EVER VOLUNTARILY RELINQUISHED A LICENSE, CERTIFICATION, OR REGISTRATION IN LIEU OF FORMAL ACTION?

17. DO YOU HAVE PENDING, OR HAVE YOU EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH CARE INSTITUTION OR AGENCY REVOKED, SUSPENDED, DENIED, RESTRICTED, LIMITED, OR PLACED ON A PROBATIONARY STATUS, OR HAVE YOU EVER VOLUNTARILY RELINQUISHED CLINICAL PRIVILEGES IN LIEU OF FORMAL ACTION?

14D. EXPIRATION DATE

(MM/DD/YYYY)

14A. LIST ALL LICENSES, CERTIFICATIONS, AND REGISTRATIONS, INCLUDING DEA, THAT YOU HAVE EVER HAD AS A HEALTH PROFESSIONAL, I.E. MEDICAL, NURSING, PHARMACY, ETC.

14C. LICENSE, CERTIFICATION OR REGISTRATION NUMBER

14B. STATE ISSUING

LICENSE

13B. STATE ISSUING

LICENSE

YES - EXPLAIN IN PART XI NO

YES - EXPLAIN IN PART XI NO

YES NO

19B. EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES (ECFMG) CERTIFICATE NUMBER 19C. ECFMG CERTIFICATE DATE

SOCIAL SECURITY NUMBERLAST NAME, FIRST NAME, MIDDLE NAME

20A. NAME OF HOSPITAL OR INSTITUTION

15. ENTER YOUR NATIONAL PROVIDER IDENTIFIER (NPI)

20D. START DATE

(MM/YY)

The following two questions apply to both your current health profession and any prior health profession.

VA FORM 10-2850DNOV 2011

YES

X - ADDITIONAL QUESTIONS

XI - REMARKS

XII - 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.

PAGE 3 OF 4

PLACE AN 'x' IN APPROPRIATE SPACE. IF YES, EXPLAIN DETAILS IN PART XI

21

AS A PARTICIPANT IN THE MEDICARE AND MEDICAID PROGRAMS, HAVE YOU EVER BEEN CONVICTED OF OR INVESTIGATED FOR MAKING FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS, REPRESENTATIONS, WRITINGS, OR DOCUMENTS REGARDING THE DELIVERY OF OR PAYMENT FOR HEALTH CARE BENEFITS, ITEMS OR SERVICES THAT WOULD BE IN VIOLATION OF THE CRIMINAL FALSE CLAIMS ACT?

22

ARE YOU NOW, OR HAVE YOU EVER BEEN, INVOLVED IN ADMINISTRATIVE, PROFESSIONAL, OR JUDICIAL PROCEEDINGS IN WHICH MALPRACTICE ON YOUR PART WAS ALLEGED? If yes, give details in Part XI, including name of action or proceedings, date filed, court or reviewing agency, and the status or outcome of the case concerning those allegations. Please also provide your explanation of what occurred. 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.

23 Do you need accommodations to perform the procedures and essential functions of the training position for which you have applied?

ITEM NO. (Include additional information requested in items above. Be sure to indicate Item number on Form to which the comment refers.)

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).

24A. SIGNATURE OF APPLICANT (sign in dark ink) 24B. DATE (mm/dd/yyyy)

ITEM NO

SOCIAL SECURITY NUMBERLAST NAME, FIRST NAME, MIDDLE NAME

VA FORM 10-2850DNOV 2011

SOCIAL SECURITY NUMBERLAST NAME, FIRST NAME, MIDDLE NAME

Disclosure of your Social Security Number (SSN) is mandatory to obtain the employment and benefits that you are seeking. Solicitation of the SSN is authorized under provisions of Executive Order 9397 dated November 22, 1943. The SSN is used as an identifier throughout your Federal career. 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 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, 'Applicants for Employment' under Title 38, U.S.C.-VA (02VA135), in the 2003 Compilation of Privacy Act Issuances. The SSN will also be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is necessary because of the large number of Federal employees and applicants with identical names and birth dates whose identities can only be distinguished by the SSN.

Public reporting burden for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data sources, gathering data, completing, and reviewing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC 20420. Do not send applications to this address.

AUTHORITY: The information requested on this 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 to determine your qualifications and suitability for appointment to a VA clinical training program. If you are appointed by VA, the information will be used to make pay and benefit determinations and in personnel administration processes carried out in accordance with established regulations and systems of records.

ROUTINE USES: Information on the form may be released without your prior consent outside the VA to another federal, state or local agency. It may be used to check the National Practitioner Health Integrity and Protection Data Bank (HIPDB) or the List of Excluded Individuals and Entities (LEIE) maintained by Health and Human Services (HHS), Office of Inspector General (OIG), or to verify information with state licensing boards and other professional organizations or agencies to assist VA in determining your suitability for a clinical training appointment. This information may also be used periodically to verify, evaluate, and update your clinical privileges, credentials, and licensure status, to report apparent violations of law, to provide statistical data, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may 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. Information will be stored in a confidential and secure VA database for purposes of processing your application and may be verified through a computer matching program. Information from this form may also be used to survey you regarding employment opportunities in VA and to solicit you perceptions about your clinical training experiences at VA and non-VA facilities.

EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Completion of this form is mandatory for consideration of your application for a clinical training position in VA; failure to provide this information may make impossible the proper application of Civil Service rules and regulations and VA personnel policies and may prevent you from obtaining employment, employee benefits, or other entitlements.

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE

SIGNATURE OF APPLICANT DATE

INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)

PAGE 4 OF 4

In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and suitability for employment, I:

AUTHORIZATION FOR RELEASE OF INFORMATION

Authorize VA to make inquiries about me to current and previous employers, educational institutions, state licensing boards, professional liability insurance carriers, other professional organizations or persons, agencies, organizations, or institutions listed by me as references, and to any other sources which VA may deem appropriate or be referred by those contacted;

Authorize release of such information and copies of related records and 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;

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; and

Authorize VA to share any information about me with the affiliated institution or training program official.

SECURITY ALERT! All Residents/Fellows who will rotate to the Edward Hines VA are required to have fingerprints

taken and complete E-Qip before they can see patients at the VA. Due to the large volume of

Residents/Fellows a short time frame for completion we need your cooperation.

PLEASE READ THE FOLLOWING CAREFULLY

1. You must get your fingerprints done at least 45 days prior to starting work. No

appointment is necessary but please bring your driver’s license and social security card

with you. Fingerprinting can be completed during the following times:

Monday to Friday from 8:00am-4:00pm. Location Bldg.17 Human Resources.

2. E-Qip is required to be completed before you start your rotation as well. In order to

have access to CPRS and write prescriptions for NARCOTICS a Federal Background

investigation request must be scheduled with the Office of Personnel Management

(OPM). E-Qip is an electronic system that can easily be accessed through your internet

browser by utilizing the following internet address for E-Qip at www.opm.gov/e-qip/,

please beware that you will only have access to the system once you have

fingerprinted an email notification will be sent to the email address in which you

provided with your paperwork. You will be given 4 business days to complete this

online questionnaire.

3. If you have been fingerprinted at the VA in past, you will be required to fingerprint

again.

4. If you are not in Chicago, you can have your fingerprints done at a local VA Hospital.

Please note that you will have to arrange an appointment. Bring this Security Alert with

you. The local VA will need the following codes to ensure your fingerprinting results

reach the Suitability Specialist at Hines VA.

SOI: VAA7; SON: 1255; OPAC: 3600 1200

5. The VA coordinator for your individual residency program may contact you prior to your

arrival to be sure that both requirements have been completed.

6. You may also receive additional information about requirements as well.

THANK YOU FOR YOUR COOPERATION

HINES VA STAFF

New Employee New hire with Hines

Student/Trainees/Resident/WOC’s (Initial appointment/rotation)

Volunteers

PIV (Re-Issuance) If your PIV card is expired, lost, stolen, de-activated (if lost requires Police Report)

Returning Students/Trainees/Residents/WOC’s

Periodic Reinvestigation If your position requires a higher level investigation (MBI or BI)

Courtesy Name and address of VA Facility:

SOI: SON:

SPECIAL AGREEMENT CHECK (SAC)

NAME: _________________________ _______________________ _________________ (Last Name) (First Name) (Full Middle Name)

SSN: _____________________________ DOB: _______________________________

(Former Name) H

ALIAS: ____________________________ RACE: _______________ SEX: _________

EYE COLOR: ______________________ HAIR COLOR: _______________________

HEIGHT: __________________________ WEIGHT: ___________________________

PLACE OF BIRTH: _______________________________________________________ (City, State, Country)

CITIZENSHIP: _________________________________ (Country)

RESIDENT ADDRESS: ____________________________________________________ (Street, City, State, Zip)

(VA Department) (Position Applied For)

SERVICE: ________________________ JOB TITLE__________________________

SCARS, MARKS, TATTOO(S): _____________________________________________

EMAIL ADDRESS: ____________________________ PHONE # ________________

ARE YOU A VETERAN? Circle one: Y/N IF YES, LAST DATE OF SERVICE: _______________

TYPE OF APPOINTMENT (check one) Employment (Paid) Fee Basis (Consultant) Resident

Volunteer Other WOC

Contractor Hines VA Contractor Building 215 Contractor Building 37

_________________________________________ __________________________ Fingerprinted by Date

ATTACHMENT A VHA DIRECTIVE 2003-032

Department of Veterans Affairs

CLINICAL TRAINEE REGISTRATION FORM

Response is mandatory. This information will be kept confidential. It will be used for reporting purposes, conducting surveys, and

improving the quality of VHA’s clinical training programs. This information will be entered in the “New Person” file in Veterans Health

Information Systems and Technology Architecture (VistA). This form may also be printed from the OAA website:

http://vaww.va.gov/oaa/policies.asp

Disclosure of your Social Security Number (SSN) is mandatory to identify individuals with identical names. 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 clinical training at VA. Solicitation of the SSN is authorized under the provisions of Executive Order

9397, dated November 22, 1943. The information gathered through the use of this number will be used as necessary for statistical studies

and personnel administration in accordance with established regulations and published notices of systems of record.

First Name MI Last Name

Social Security Number

Home Email Address

Street Address

City State Zip

Start Date/End Date of Hines Training WOC or Paid Today’s Date

PGY Level

Specialty School

Degree Level of Educational Program: (mark only one) Certificate/Diploma Associate

Post-master’s fellowship Doctoral

Baccalaureate Master’s

Postdoctoral (other than residents) Residency/Fellowship

Program of Study: (mark only one)

(Discipline that best describes the current program of study) Audiology Chaplaincy

Medical/Surgical Support (Respiratory Tech, Biomedical Tech, etc.)

Dentistry Nurse Anesthetist Dietetics Nursing Health Information Optometry Health Services Research & Development Other Imaging (Radiologic/Ultrasound Tech, etc.) Pharmacy Laboratory Physician Assistant Medical Student Podiatry Medical Resident/Fellow Psychology Medical Post-residency Physician in a VA Special Fellowship (Ambulatory Care, National Quality Scholars, Women’s Health, etc.)

Rehabilitation (OT, PT, KT, etc.) Social Work Speech–Language Pathology

What is the LAST YEAR that you anticipate being in a training program at this VA facility?

2009 2012

2010 2013

2011 2014

Service ____________________________________________

2015

2016

2017

4/1/09 VA FORM

10-0410 MAY 2003

10/11/07

Updated 12/18/09, 1/25/13

HINES HOSPITAL INFORMATION SECURITY PROGRAM

Laptop Agreement Form

As you have seen, the VA takes a layered approach to laptop security. There are many ways to logically protect the

data on your laptop including: full disk encryption, VPN technology, antivirus and personal firewall applications,

and operating system and application patching. These methods do a great job protecting data that is found on VA

laptops. But, without physical controls, good laptop security can not be achieved. We covered the “low tech”

solutions like labeling and locking your laptop, and also common sense measures like how to protect your laptop

from theft while on travel status.

In conclusion there are three main points that you should take with you.

1) Follow all VA policies in regards to protecting your laptop and the data on it. No one wants to be the next

story in the newspaper regarding laptop loss at a federal agency.

2) Be aware of all the controls, both logical and physical, that need to be in

place to secure your laptop and the data that resides on it.

3) Take this knowledge with you and share it with your co-workers.

Spread the word about information security.

If you see a practice that isn’t secure, let someone know.

It is everyone’s responsibility to keep the data of our nation’s heroes secure.

I have reviewed this document with management, and I understand my responsibility

for protecting VA information assets while using them in uncontrolled environments. I understand that the

implementation and the support of the protection activities described in this document will assist in the prevention

of unauthorized access to VA information or Government Furnished Equipment that is under my control. I agree

to conform to the direction provided to me to the best of my ability.

____________________________________________

Employee or Contractor Name (PLEASE PRINT)

____________________________________________ ____________________________

Employee or Contractor Signature Date

I have met with the above-named user and reviewed the security precautions that should be taken while they are

working in uncontrolled environments.

____________________________________________

Supervisor Name (PLEASE PRINT)

____________________________________________ _____________________________

Supervisor Signature Date

Mandatory Training for Trainees TMS Self Enrollment for Hines VA Hospital

This is the data you will need to enter/create, to enroll in the required online training. The SOLE purpose of this form is to help you prepare to enroll. You do NOT need to submit this form to anyone. You should NEVER give your password/security question information to anyone else- that would constitute a breach of security.

New Link to Enroll in Training: https://www.tms.va.gov/plateau/user/login.do *Indicates Required Field <Click> Create New User on the orange/red bar on your screen TMS Self-Enrollment - Information trainees must enter:

*Personal Email Address:

*Password (will include at least one of each of the following: CAPITAL letter, lowercase letter, number and character, and will be from 8-20 characters in length )

*Security Question:

*Security Answer:

* Social Security Number:

*Date of Birth (MM/DD/YYYY):

*Legal First Name:

*Legal Last Name:

Middle Name (Optional):

Phone Number:

VA City: Hines

VA State: Illinois

*VA Location Code: HIN

*Health Professions Trainee type: (Select from following list)

Physician Resident

Dental

All other Health Professions

*Specialty/Discipline: (Select from the list) (List – dynamic based on trainee choice

above)

*VA Point of Contact First Name (Insert First Name of Affiliate Coordinator)

*VA Point of Contact Last Name (Insert Last Name of Affiliate Coordinator)

*VA Point of Contact Email Address (Insert Email Address of Affiliate

Coordinator)

VA Point of Contact Phone Number (Not required)

After completing the registration process, you will login with your new TMS training UserID and Password, and will be taken to a screen where you will see that the VA 3185966, VHA Mandatory Training for Trainees (MTT), has been assigned to you.

Quick Reference Guide for e-QIP Applicants

Find At

https://www.opm.gov/investigations/e-qip-

application/

This Quick Reference Guide is provided to assist you in completing the Questionnaires for

National Security, Public Trust and Non-sensitive positions using the Electronic Questionnaires

for Investigations Processing (e-QIP) system. Please follow the guide step-by-step to ensure that

your questionnaire is completed properly.

e-QIP is a web-based automated system that was designed to facilitate the processing of standard

investigative forms used when conducting background investigations. e-QIP allows you to

electronically enter, update, and transmit your personal investigative data over a secure internet

connection to a requesting agency. The requesting agency will review and approve the

investigative data.

Why am I being required to have a background investigation?

The U.S. Government conducts background investigations to determine if applicants or

employees meet the suitability or fitness requirements for employment, or are eligible for access

to Federal facilities, automated systems, or classified information. All persons must be properly

investigated and adjudicated to be issued a credential and to be authorized access to classified

information.

The scope and type of background investigation varies depending on the duties and access

requirements for the position, as does the amount of time it takes to be completed. The

employing or sponsoring agency is responsible for determining the appropriate level of

investigation to be conducted based on current rules and procedures.