Fl 10-341a Form - Appraisal Of Applicant (Department Of Veterans Affairs)

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DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

Dear

has applied to the Department of Veterans Affairs for

employment as a

and has given your name or institution

as a reference.

To help us determine if this applicant meets the requirements for employment, we would appreciate

your completing the questions on the reverse side of this letter. Please be entirely frank and answer all

applicable questions as fully and specifically as you can.

For your convenience, we have enclosed a self-addressed envelope that requires no postage. Thank you

for your help in this matter.

Sincerely yours,

The information you provide on the individual named above will be disclosed to the individual on his or her request.

Paperwork Reduction Act and Privacy Act Notices. We are required to notify you that this information collection is in accordance with the clearance

requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to

average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data

needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no

person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control

number.Title 38, United States Code, Chapter 73, grants the VA the authority to request such information. Please understand that we regard the provision

of this information on your part as voluntary. Response is voluntary, however failure to provide the information may result in our inability to determine

the applicant's qualifications. This collection of information is intended to provide a tool to judge an applicant's suitability for employment. Information

on the form or the form itself 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 (HIPDB) or List of Excepted Individuals (LEIE) Data Banks which are administered by the Department of Health and

Human Services, to State licensing boards, and/or appropriate professional organizations or agencies to assist the VA in determining the suitability of the

applicant for a clinical training appointment. This information may also be used to periodically verify, evaluate and update clinical privileges, credentials

and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper request, 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. The information you supply 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 at any time.

FL 10-341a

(over)

Page 1 of 2

MAY 2006 (R)