Fillable Stanford Vapahcs Requirements Checklist printable pdf download

In-Processing Requirements Checklist

VA PALO ALTO HEALTH CARE SYSTEM (VAPAHCS)

Full Name: ______________________________________

Academic Rotation 2016 - 2017

Department: ______________________________________

(Packet due

NO LATER THAN

5/13/2016)

Check one: Intern

Resident

or Fellow

Specialty

Check one: PGY Level: I

III

New to VA Palo Alto Health Care System? (Check) Yes

or No

THE DOCUMENTS ON THIS LIST ARE ALL REQUIRED TO BE SUBMITTED WITH YOUR PACKET, PLEASE READ THE

INSTRUCTIONS FOR EACH REQUIREMENT CAREFULLY TO AVOID DELAYS. DO NOT STAPLE!!

 Requirement # 1 – Information Required for Electronic Fingerprint Verification Form

(Complete all fields on this form,

see VAPAHCS Welcome Letter for more detailed instructions)

NOTE: Make arrangements with your House Staff Coordinator to travel to VAPAHCS for fingerprinting

during orientation

; also check for instructions on how to get this done at a VA facility in your State).

 Requirement # 2 – “I-9 Employment Verification Form”, correct version expires 3/31/2016 (Required

by the U.S. Department of Homeland Security, see 5 page attachment: instructions and form to complete).

 Requirement # 3 - OF 306 – Declaration for Federal Employment

(SEE “SAMPLE OF 306” for instructions on how to fill correctly).

 Requirement # 4 –

Follow instructions to self-register on the TMS/training website. You will need to save

your certificate in pdf format to send with packet, and print a copy to bring with you for your VA rotation.

 Requirement # 5 – (FOR INFO) PIV/Photo Identification Documentation Criteria

The names on both forms of ID must match exactly – review instructions, make clear and easy to read

copies of IDs and submit with this packet, but also bring your original documents to present at the time

of your VA orientation and processing.

 Requirement # 6 - VA Form 10-2850d – “Application for Health Professions Trainees”

(Do not forget to sign/date “Authorization for Release of Information”, complete all fields).

NOTE: If you are not a citizen¸ provide a legible copy of authorization documents (i.e., Visa, permit, etc.)

 Requirement # 7 – Trainees Info Data Sheet Form

(Complete all information here and do not forget to include license, DEA and NPI numbers; current address/phone

number/contact information will be updated again, once you begin your training rotation).

 Requirement # 8 - Previously Issued VAPAHCS ID Badge, if Applicable (no attachment).

NOTE: If you were previously issued a VAPAHCS ID Badge and did not return it when your last rotation at Palo

Alto ended, you must return it before you will be issued a new VAPAHCS ID Badge. A $10 fine is assessed

for unreturned VAPAHCS ID Badges.

IMPORTANT: If you already rotated at a different VA facility/hospital, in any status (i.e., medical

student, Intern, Resident, Fellow, etc.), please provide the following information:

LOCATION (Hospital/Facility) NAME:

Issued a PIV badge? YES

Dates of most recent training:

If you are currently working at another VA, when is the last date you will use your computer access

at this facility?

Important – IT must change account to our domain,

which may take a few weeks. Your cooperation providing this information is greatly appreciated.

CONTACT YOUR SPECIALTY HOUSE-STAFF COORDINATOR, IF QUESTIONS.

DO NOT ALTER THIS FORM IN ANY WAY

Stanford Vapahcs Requirements Checklist

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