OMB Number: 2900-0621 Est. Burden: 1 hour
CREDENTIALS TRANSFER BRIEF
Privacy Act and Paperwork Reduction Act Information The information requested is solicited under Title 38, United States Code, Chapters 73 and 74. This is collected primarily to determine your qualifications and suitability for employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. Information may be released without your prior consent where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute outside the VA to another Federal, State or local agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, the American Medical Association, Federation of State Medical Boards, and/or appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically verify, evaluate and update your clinical privileges 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 also be released without your prior consent to Federal agencies, State licensing boards, the Federation of State Medical 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 may be verified through a computer matching program at any time. The Paperwork Reduction Act of 1995 requires us to notify you that this information is collected 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 60 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. No person will 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. Submission of this information is voluntary and failure to respond will have no adverse effect on any benefits to which you otherwise may be entitled.
NOTE: Any item not verified at the primary source is listed with notation of information substituted. NAME (Last, First, Middle Initial) TYPE OF APPOINTMENT 1. IDENTIFYING DATA SOCIAL SECURITY NUMBER SPECIALTY 2. EDUCATION AND TRAINING
Degree or Specialty Education Internship Residency Institution Location Completion Date Primary Source Verified
Y Y Y Y
N N N N N
3. ECFMG CERTIFICATE NUMBER ISSUE DATE 4. STATE MEDICAL LICENSE
State License Type License Number Expiration Date Primary Source Verified
Y Y Y
CERTIFICATIONS 5. 6.
VA FORM JUL 2005
N N N
STATE DANGEROUS CONTROLLED SUBSTANCE (CDS) SPECIALTY BOARD CERTIFICATION
CERTIFICATION NUMBER SPECIALTY
EXPIRATION DATE EXPIRATION DATE Page 1 of 2
EXISTING STOCK OF VA FORM 10-0376a, FEB 2002, WILL BE USED.
CERTIFICATIONS CONTINUED SUBSPECIALTY BOARD CERTIFICATION 7. 8. 9. 10. CERTIFICATION NUMBER EXPIRATION DATE EXPIRATION DATE EXPIRATION DATE
TYPE OF CERTIFICATION BASIC CARDIAC LIFE SUPPORT (BCLS) & ADVANCED CARDIAC LIFE SUPPORT (ACLS) CERTIFICATION CLINICAL PRIVILEGES GRANTED IN (Product Service Line) (Attach Copy)
NATIONAL PRACTITIONER DATA BASE QUERY(S) DATE: CLINICAL SUMMARY a. attested to not having a physical (Provider's Name)
or mental health condition that would adversely affect the ability to carry out the clinical duties requested from (Name of the VA Medical Center or Health Care System where currently appointed) ; is known to be clinically
competent to practice the full scope of privileges granted at this facility, to satisfactorily discharge professional and ethical obligations, as attested to by telehealth services. , and is known to be providing (Name and telephone number of Service Chief) has or (Name of Service Chief) competence to perform granted privileges. does not have additional information relating to
credentialing file and the documents contained therein have
been reviewed and verified as indicated above. The information conveyed in this memorandum reflects credential status as of . (Date) . The credentialing file contains no additional information relevant to the privileging of at your Medical Center.
(Provider's Name) REMARKS (Attach an additional sheet if necessary.)
11. TYPED NAME OF MEDICAL STAFF COORDINATOR
12. SIGNATURE OF MEDICAL STAFF COORDINATOR
13. TELEPHONE NUMBER
14. FAX NUMBER
15. PROVIDING FACILITY NAME
VA FORM JUL 2005
Page 2 of 2