Begin Station Clearance on your last day of Rotation after 2pm (Monday-Friday) Ending in Academic Affiliations office (Bldg 20, Room 200) no later than 4:00 pm RESIDENT / STUDENT / TRAINEE CLEARANCE FORM FULL NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. CURRENT MAILING ADDRESS DATE TITLE OF POSITION STATION NO. SERVICE/ SECTION 516 Resident Student Trainee THE RESIDENT/ STUDENT/TRAINEE IS: EFFECTIVE DATE THE RESIDENT/ STUDENT/TRAINEE IS (Check one) VETERAN NON VETERAN COMPLETING FM: TO: (give dates): CURRENT ROTATION Service Coordinator/ Preceptor’s INITIALS ARTICLES DEPARTMENTS/STAFF OFFICES CLEARANCE OFFICIAL’S INITIALS Turn in all assigned Keys; Assigned Service: Exit Interview with your Program Coordinator Turn in all outstanding Timekeeping/Calendars Disused in by service ADPAC (Pd Residents) to service coordinator. Complete/sign all CPRS data entries HIMS Medical Records- – call x 17009 **Clear Medical Records prior to 4 pm** Visit OIT to disuse Network account and if OIT Help Desk Bldg 2 Rm 211A applicable turn in VA issued-pager Mon-Fri 08:00am to 4:30pm Turn in uniforms and/or lab coats (if applicable) EMS Uniforms Bldg 100, Rm 1B149 – – Last day of your last http://www.va.gov/oaa Complete Learners’ perception survey per Office of Rotation! Academic Affiliations Is Resident or Student returning in the Yes No next 90 days? Is Resident or Student also an employee Yes No at Bay Pines? Forwarding Mailing Address: Street: Apt/Bldg #: City: State: Zip Code: Forwarding Email Address: Telephone Number: Area Code: #: EXTENSION DATE SIGNATURE OF PROGRAM COORDINATOR PRINTED NAME OF COORDINATOR ARTICLES CLEARANCE OFFICIAL’S DEPARTMENTS/STAFF OFFICES INITIALS Turn in BPVAHCS ID Police Service, Bldg 37, Rm 150 Turn in Parking Decal (if applicable) Deliver completed form to Bldg 20 Room 200 or email to VHABAY Academic Affiliations before Education Service 20, Rm 200 –Bldg 4:00 pm on last day of Rotation. To be completed by Academic Affiliations Staff   Initials:_______ Update OAA Initials:_______ De-activate User in TMS student database Date: ________ Date: ________
Begin Station Clearance on your last day of Rotation after 2pm (Monday-Friday) Ending in Academic Affiliations office (Bldg 20, Room 200) no later than 4:00 pm RESIDENT / STUDENT / TRAINEE CLEARANCE FORM FULL NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. CURRENT MAILING ADDRESS DATE TITLE OF POSITION STATION NO. SERVICE/ SECTION Resident Trainee Student 516 THE RESIDENT/ STUDENT/TRAINEE IS: THE RESIDENT/ STUDENT/TRAINEE IS (Check one) EFFECTIVE DATE COMPLETING CURRENT ROTATION (give dates): FM: TO: VETERAN NON VETERAN ARTICLES Service Coordinator/ Preceptor’s INITIALS DEPARTMENTS/STAFF OFFICES CLEARANCE OFFICIAL’S INITIALS Turn in all assigned Keys; Exit Interview with your Program Coordinator Turn in all outstanding Timekeeping/Calendars (Pd Residents) to service coordinator. Assigned Service: Disused in by service ADPAC Complete/sign all CPRS data entries **Clear Medical Records prior to 4 pm** HIMS – Medical Records- call x 17009 Visit OIT to disuse Network account and if applicable turn in VA issued-pager OIT Help Desk Bldg 2 Rm 211A Mon-Fri 08:00am to 4:30pm Turn in uniforms and/or lab coats (if applicable) EMS – Uniforms – Bldg 100, Rm 1B149 Complete Learners’ perception survey per Office of Academic Affiliations http://www.va.gov/oaa Last day of your last Rotation! Is Resident or Student returning in the next 90 days? Yes No Is Resident or Student also an employee at Bay Pines? Yes No Forwarding Mailing Address: Street: Apt/Bldg #: City: State: Zip Code: Forwarding Email Address: Telephone Number: Area Code: #: SIGNATURE OF PROGRAM COORDINATOR PRINTED NAME OF COORDINATOR EXTENSION DATE ARTICLES CLEARANCE OFFICIAL’S INITIALS DEPARTMENTS/STAFF OFFICES Turn in BPVAHCS ID Turn in Parking Decal (if applicable) Police Service, Bldg 37, Rm 150 Deliver completed form to Bldg 20 Room 200 or email to VHABAY Academic Affiliations before 4:00 pm on last day of Rotation. Education Service –Bldg 20, Rm 200  To be completed by Academic Affiliations Staff  De-activate User in TMS Initials:_______ Date: ________ Update OAA student database Initials:_______ Date: ________
Clearance_Form.docx