Va Sponsored Woc Request printable pdf download

VA SPONSORED WOC REQUEST (All Others)

(PLEASE PRINT)

In accordance with VA Handbook 5005, Part II, Chapter 3, approval is requested for the following Without

Compensation (WOC) appointment(s) under 38 U.S.C. 7405(a)(1) appointments for assignments to the ____________

Service of the Eastern Colorado Health Care System. The appointment will be effective _______________ through

____________(not to exceed 1 year). In accepting this assignment, the appointee, _____________________,

understands that he/she will receive no monetary compensation, is not entitled to any benefits, and that this

agreement may be terminated at any time. I understand that WOC candidates may not provide their services at any

ECHCS facility until their WOC request has been approved and an appointment letter has been issued to the

candidate.

NAME: ___________________________________________________________________________________

DATE OF BIRTH: ________________________COUNTRY OF BIRTH: __________________________________

SOCIAL SECURITY NUMBER: _______________________________

US CITIZEN:

YES

NATURALIZED US CITIZEN

NON-CITIZENS MEMO

(if applicable), PLEASE ATTACH THE APPROVED NON-CITIZEN MEMO

QCVL ATTACHED

OF-306

COMPLETED APPLICATION: Resume/CV

VA Form 10-2850 for Physicians

VA Form 10-2850A for Nurses

VA Form 10-2850c for Associated Health Occupations

FINGERPRINTS TAKEN

APPOINTMENT IS LESS THAN 180 DAYS IN AN AGGREGATE YEAR

(2 days or less per week)

APPOINTMENT IS MORE THAN 180 DAYS IN AN AGGREGATE YEAR

SF-85/e-QIP INITIATED

POSITION IS EXPECTED TO HAVE CONTACT WITH: HUMAN SUBJECTS

ANIMAL SUBJECTS

NONE

PLEASE INCLUDE THE BELOW ITEMS IN YOUR COMPLETED PACKET

Completed Application {VA Form 10-2850a, VA Form 10-2850c or VA Form 10-2850}

Resume/CV

OF-306

Form I-9 (Complete section 1)

TQCVL (required for all fellows)

Declaration of Health (If no TQCVL)

Pre-App for Credentialing (if applicable)

VetPro Enrollment (if applicable)

E-QIP Enrollment form (if applicable)

Va Sponsored Woc Request