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Congratulations on your new appointment as a Duke Resident at the Durham VA Health Care System. We are excited to have you on the team. We hope your time with us is both exciting and

motivating. Below you will find links to the paperwork required for Duke Residents. Complete, print out, sign and turn in all paperwork together to your points of contact identified below.

Again, congratulations and welcome to the team.  ITEMS LISTED BELOW MUST BE RECEIVED BY THE DURHAM VAHCS NLT APRIL 30, 2021:    MAILING ADDRESS: Durham VA Medical Center Duke Residency

Durham VA Medical Center [insert mail code from Point of Contact document] Attn: [insert name of DVAHCS point of contact from the Point of Contact document] 508 Fulton Street Durham, North

Carolina 27705  (PLEASE DOWNLOAD EACH DOCUMENT TO YOUR COMPUTER IN ORDER TO EDIT AND INPUT YOUR INFORMATION.) VA FORM 10-2850D APPLICATION FOR HEALTH PROFESSIONS TRAINEE DATED NOV 2011

INSTRUCTIONS FOR COMPLETING THE VA FORM 10-2850D PAGE 1 1 A. Name – (PROVIDE FIRST, FULL MIDDLE, & LAST NAME). IF YOU DON’T HAVE A MIDDLE NAME, INDICATE “NO MIDDLE NAME”.  IF YOU HAVE

ONLY INITIALS IN YOUR NAME, PROVIDE THEM AND INDICATE “INITIAL ONLY”.  * Complete maiden names, nick names, other spellings, or name changes * Address - Complete address to include zip code

3A &3B. Telephone – Telephone number to include area code for morning and evening * Social Security # - Complete 9-digit social security number 5A. Primary Email Address – Best email

address to reach you 5B.  Alternate Email Address - * Date of Birth – Month, Day, and Year of birth * Training Facility (City, State) – Durham, NC 7B& 7C – check the unknown box 8A – Are

you now in the U.S. Military – select the response that applies to you 8B.  Are you in the Reserves of National Guard? – select the response that applies to you 8C. Branch of Service –

enter as appropriate or enter N/A or None 8D. Start Date of your Degree, Month and Year 9A. Enter citizenship status 9B. Enter your country of citizenship Complete items 10A, 10B, 10C and

10D only if you are not a US Citizen PAGE 2 (PLEASE PROVIDE YOUR COMPLETE NAME & SSN AT TOP OF THE PAGE) ITEM V Current Clinical License or Certifications – Complete all fields, if none,

N/A or None Item VI Previous Clinical License or Certifications - Complete all fields, if none, N/A or None 15 – ENTER YOUR NATIONAL PROVIDER IDENTIFIER (NPI) 16 – COMPLETE 17 – COMPLETE

Item VII – Education and Training 18 A – Enter all schools after high school in chronological order 18B – Enter address of schools 18C – Enter start date for program 18D – completion date

18E – Diploma earned 18F – Field of Study Item VIII International Graduates – If you are an international student, complete all fields Item IX Internship, Residency, and Fellowship – If

apply, complete all fields with full name of school and complete physical address WITH City, State and Zip or N/A or None PAGE 3 (PLEASE PROVIDE YOUR COMPLETE NAME & SSN AT TOP OF PAGES

2-4. SIGN PAGES 3 & 4. Item X Respond to questions 21, 22 & 23 Item XI Additional space for previous responses Sign and date page 3 at the bottom of the form PAGE 4 (PLEASE PROVIDE

YOUR COMPLETE NAME & SSN AT TOP OF PAGES 2-4. SIGN PAGES 3 & 4) Authorization for Release of Information – Read and Check all boxes, date, sign and read privacy notice Name and

Social Security number should be on top of every page where specified SIGN AND DATE PAGE 4 FORM (OF) 306, DECLARATION FOR FEDERAL EMPLOYMENT Instructions for completion of the OF-306: *

(PROVIDE FIRST NAME, FULL MIDDLE NAME, & LAST NAME). IF YOU DON’T HAVE A MIDDLE NAME, INDICATE “NO MIDDLE NAME”.  IF YOU HAVE ONLY INITIALS IN YOUR NAME, PROVIDE THEM AND INDICATE

“INITIAL ONLY” * Social security number * Place of birth * U.S. citizenship status * Date of birth * Other names ever used- Complete maiden names, nick names, other spellings, or name

changes * Phone numbers * Selective service registration * Background information about convictions, firings, delinquent federal debt * Whether your relatives work for the agency or

government organization to which you are submitting this form * Whether you receive or have ever applied for retirement pay, pension, or other retired pay based on military, federal civilian

or District of Columbia Government service * Signature (Sign as applicant) * Date * Date you left last federal job if any * Whether you waived basic life insurance or any type of optional

life insurance when you last worked for the federal government, whether you later cancelled that waiver POINTS OF CONTACT WELCOME LETTER (FOR YOUR RECORDS)   AM I ELIGIBLE - Download this

checklist to be sure you meet all eligibility requirements to train at VA facilities.  APPOINTMENT LETTER (Review, sign bottom and return this document to your DVAHCS POC)    SCREENING

CHECKLIST  (HR Checklist (VA FORM 10-0453) DETERMINATION & CERTIFICATION OF ENGLISH LANGUAGE PROFICIENCY (Fill in your information. Return this document to your DVAHCS POC) RANDOM DRUG

TESTING NOTIFICATION AND ACKNOWLEDGEMENT (Fill in your information and return this document to your DVAHCS POC) FINGERPRINT PREP SHEET (Complete ALL BOXES and return to your DVAHCS POC) 

COURTESY FINGERPRINTING: YOU MUST CONTACT A NEARBY VA, TO BEGIN THE FINGERPRINT CLEARANCE PROCESS PRIOR TO ARRIVING IN DURHAM (PRESENT THE DVAMC APPOINTMENT LETTER AND THE COURTESY

FINGERPRINTS DOCUMENT TO YOUR LOCAL VA FACILITY.  LOCATIONS FOR COURTESY FINGERPRINTS CAN BE FOUND at  HTTPS://WWW.OIT.VA.GOV/PROGRAMS/PIV/LOCATIONS.CFM  Advise your DVAHCS POC when and

where courtesy prints were taken. DO NOT HESITATE TO COMPLETE THIS REQUIREMENT VHA MANDATORY TRAINING FOR TRAINEES (MTT): MUST BE COMPLETED PRIOR TO SUBMITTING PAPERWORK   Go to TMS

website-Self register and complete MTT. You need the following information to complete self-registration: VA Location: DUR   PROVIDE A COPY OF YOUR COURSE COMPLETION TO YOUR DVAHCS POC  WHEN

YOU SUBMIT YOUR PAPERWORK *TRAINEES WHO PREVIOUSLY HAD TMS ACCOUNTS: CHANGE YOUR EMAIL ACCOUNTS IN TMS TO ENSURE YOU CAN ACCESS THE EMAIL ACCOUNT LISTED.  IF YOU PREVIOUSLY HAD A TMS

ACCOUNT AND CAN NO LONGER ACCESS IT, PLEASE SEND AN EMAIL TO [email protected] REQUESTING ASSISTANCE NON-US CITIZEN REQUEST MEMO must submit include a copy of their visa and

passport   PERSONAL IDENTITY VERIFICATION (PIV) (Submit a copy of your social security card and driver's license, state ID or VISA to your DVAHCS POC NLT April 30, 2021)  Please notify

POC of any changes to Driver’s License, State ID or VISA prior to orientation.    LOST, STOLEN, DESTROYED, OR DAMAGED PIV BADGE (If previously issued a PIV badge that has been lost, stolen,

or destroyed, please fill out the PIV Memo through your signature line. Return document your DVAHCS POC)  CURRENT PIV BADGE HOLDERS (If you have a PIV badge from another VA facility, please

advise your DVAHCS POC)  NPI NUMBER (Include your NPI number on your VA Form 10-2850 and print page with NPI Number and send page to your DVAHCS POC)   IDENTIFICATION (Bring two 

original/current ID’s from the List of Acceptable Forms of ID to your DVAMC orientation/appointment. School ID will not suffice.)  STANDARD FORM 61 APPOINTMENT AFFIDAVITS REVISED AUGUST 2002

Do not sign or get notarized, fill in top portion using Health Professions trainee as the Position in which appointed; Department: VA; Bureau or division: VHA; Place of Employment: DVAHCS.