1 Name of Nominated Fellow 3 Program Non Clinician – Complete Section 1 Select 2 Clinician Associated Health/Nursing Complete Section 1 & 2 one Clinician Physician/Dentist – Complete Section 1,2 & 3 SECTION 1 MUST BE COMPLETED FOR ALL NOMINATIONS Complete (items 1-24) Application for Health Professions Trainees 4 Signed by DEO (item 12A) VA Form 10-2850d Signed by Fellow (item 24A) Citizenship documents verified: Applicant is a US Citizen Associated Health applicants must be US 5 Citizens Non Us Citizenship Employment Physicians/Dentists Only: Non US Citizen- appropriate immigration status for VA Eligibility Verified appointment and pay 6 Education and training Verified If the applicant is VA staff, statement of voluntary acceptance of reduced pay 7 Verified Not VA Staff or file for the duration of fellowship training obtained and kept on SECTION 2 ADDITIONAL REQUIREMENTS FOR ALL CLINICIANS Verified or 8 Professional license at least one state license is unrestricted and current No License: TQCVL Verified 9 Approved to provide clinical services Verified SECTION 3 ADDITIONAL REQUIREMENTS FOR PHYSICIANS AND DENTISTS Verified Complete or Completed an ACGME/AOA/ADA Residency or Training in 10 progress Verified scheduled completion Verified or Mid Residency Physician or 11 ABMS/AOA Physician Specialty Certification: was completed within prior Residency 24 months and not yet certified COMMENTS OR EXPLAINATIONS FOR MISSING OR NEGATIVE INFORMATION 12 Please Print Name VA Credentialing or Human Resource Official Telephone # Signature of VA Credentialing or Human Resource Official Date
1 Name of Nominated Fellow 2 Select one Non Clinician – Complete Section 1 Clinician Associated Health/Nursing Complete Section 1 & 2 Clinician Physician/Dentist – Complete Section 1,2 & 3 3 Program SECTION 1 MUST BE COMPLETED FOR ALL NOMINATIONS 4 Application for Health Professions Trainees VA Form 10-2850d Complete (items 1-24) Signed by DEO (item 12A) Signed by Fellow (item 24A) 5 Citizenship documents verified: Associated Health applicants must be US Citizens Physicians/Dentists Only: Non US Citizen- appropriate immigration status for VA appointment and pay Applicant is a US Citizen Non Us Citizenship Employment Eligibility Verified 6 Education and training Verified 7 If the applicant is VA staff, statement of voluntary acceptance of reduced pay for the duration of fellowship training obtained and kept on file Verified or Not VA Staff SECTION 2 ADDITIONAL REQUIREMENTS FOR ALL CLINICIANS 8 Professional license at least one state license is unrestricted and current Verified or No License: TQCVL Verified 9 Approved to provide clinical services Verified SECTION 3 ADDITIONAL REQUIREMENTS FOR PHYSICIANS AND DENTISTS 10 Completed an ACGME/AOA/ADA Residency or Training in progress Verified Complete or Verified scheduled completion 11 Physician Specialty Certification: ABMS/AOA Verified or Mid Residency Physician or Residency was completed within prior 24 months and not yet certified COMMENTS OR EXPLAINATIONS FOR MISSING OR NEGATIVE INFORMATION 12 Please Print Name VA Credentialing or Human Resource Official Telephone # Signature of VA Credentialing or Human Resource Official Date
ADVANCED_FELLOW_NOMINATION_CHECKLIST.docx