Program Coordinator Trainee

INITIAL TRAINEE APPLICATION

PACKAGE CHECKLIST

Salisbury VA Health Care System - AY 2022-2023

First Name: Middle Name: Last Name:

(Use Full Legal Name as it appears on your Government/State issued ID- (NO NICKNAME)

Affiliate: Discipline:

Email Address: Rotation Dates:

Forms to Be Completed & Verified by the Institution:

TQCVL (To be completed by the Institution)

All Information required to be verified on the TQCVL must be completed by the Institution

Documentation per CDC Guidelines & VA Policy for Healthcare workers, to include Influenza Vaccination, Hep B, MMR, Varicella, TDAP & Meningococcal. https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html

Screened against the Health and Human Services’ List of Excluded Individuals and Entities (LEIE) and the National Practitioner Data Bank (NPDB)

Selective Service Status Screening (Male Born Residents only)

Documents to Be Completed:

VA Form 10-2850D, Application for Health Professions Trainees

VA Form OF-306, Declaration for Federal Employment

Fingerprint Request Form (NOTE: Please bring two (2) IDs for your Fingerprint and Badge Appointments. One must be a picture ID, such as Driver’s License and the other could be a Passport, Social Security Card or Birth Certificate. Must be original documents. Please see Identity Source Document for documents that are accepted.)

Proof of COVID Vaccination or Qualified Exemption (COVID-19 VACCINATION FORM 10230)

HPT-Testing-Acknowledgement

Local Policy Handout & Links

Personal & Emergency Contact Sheet

Without Compensation Letter (Appointment)

PIV Do & Don’t

Vehicle Decal Registration Form

Resume/CV – Please provide a copy of your resume with your packet.

To Be Completed Online – PROVIDE CERTIFICATE with the above documents:

Mandatory Training for Trainee (MTT) Course, which includes Rules of Behavior –

Self-Enrollment on TMS-VA Website: https://www.tms.va.gov/SecureAuth35/

Instructions attached: expires one (1) year from date of completion.

Document to Be Completed at the Salisbury VA (by individual service or Research & Academic Affairs):

VA Form SF-61, Appointment Affidavit

At Completion of Rotation:

Clearance Sheet/Turn in ID Badge

Employee’s Records Clearance – VA Form 10-0708

VA Trainee Satisfaction Survey (VA-TSS) (Trainee to complete and provide certificate of completion prior to end of rotation.)

Access page: www.va.gov/oaa/surveys

Direct link to survey: https://www.research.net/r/vatssmobile

As the Affiliate Program Coordinator, I verify the information is complete and accurate.

Signature Date

Contact this candidate