Va Form 10-2850d - Application For Health Professions Trainees Page 4

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LAST NAME, FIRST NAME, MIDDLE NAME

SOCIAL SECURITY NUMBER

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 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.

SIGNATURE OF APPLICANT

DATE

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE

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.

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

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.

VA FORM 10-2850D

PAGE 4 OF 4

NOV 2011