Fillable Printable VA Form Letter 10-341a
Fillable Printable VA Form Letter 10-341a
VA Form Letter 10-341a
DEPARTMENT OF VETERANS AFFAIRS
In Reply Refer To:
employment as a
as a reference.
Sincerely yours,
has applied to the Department of Veterans Affairs for
and has given your name or institution
The information you provide on the individual named above will be disclosed to the individual on his or her request.
(over)
FL 10-341a
MAY 2006 (R)
Paperwork Reduction Act and Privacy Act Notices. We are required to notify you that this information collection is 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 30 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. Respondents should be aware that notwithstanding any other provision of law, no
person shall 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.Title 38, United States Code, Chapter 73, grants the VA the authority to request such information. Please understand that we regard the provision
of this information on your part as voluntary. Response is voluntary, however failure to provide the information may result in our inability to determine
the applicant's qualifications. This collection of information is intended to provide a tool to judge an applicant's suitability for employment. Information
on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or local agency. It may be used to
check the National Practitioner (HIPDB) or List of Excepted Individuals (LEIE) Data Banks which are administered by the Department of Health and
Human Services, to State licensing boards, and/or appropriate professional organizations or agencies to assist the VA in determining the suitability of the
applicant for a clinical training appointment. This information may also be used to periodically verify, evaluate and update clinical privileges, credentials
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 be released without your prior consent to Federal agencies,
State licensing 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 will be stored in a confidential and secure VA database for purposes of processing your application
and may be verified through a computer matching program at any time.
Dear
To help us determine if this applicant meets the requirements for employment, we would appreciate
your completing the questions on the reverse side of this letter. Please be entirely frank and answer all
applicable questions as fully and specifically as you can.
For your convenience, we have enclosed a self-addressed envelope that requires no postage. Thank you
for your help in this matter.
Page 1 of 2
4. WHAT HAS BEEN YOUR RELATIONSHIP WITH THE APPLICANT?
OMB No. 2900-0205
Estimated Burden: 30 minutes
A. APPLICANT INFORMATION
2. SOCIAL SECURITY NUMBER
1. NAME OF APPLICANT
3. HOW LONG HAVE YOU KNOWN THE APPLICANT
PROFESSIONALLY?
NO (if "YES,"explain in Remarks)
5. APPLICANT WAS EMPLOYED
7. AVERAGE HOURS APPLICANT WORKED
PER WEEK
6. DATES OF EMPLOYMENT
FROM
TO
PART-TIME
FULL-TIME
NOTE: Please check the appropriate column for each performance factor
PERFORMANCE FACTORS UNSATISFACTORY WEAK SATISFACTORY
HIGHLY
SATISFACTORY
EXCELLENT
8a. CLINICAL KNOWLEDGE
8b. CLINICAL COMPETENCE/SKILLS
8c. EMOTIONAL STABILITY
8e. DEPENDABILITY
8f. INSTRUCTIONAL SKILLS
8g. ADMINISTRATIVE COMPETENCE
10. REASON APPLICANT LEFT YOUR EMPLOYM ENT
NO (if "NO,"explain in Remarks)
YES
YES
NO (if ''YES," explain in Remarks)
YES
YES
C. FOR EDUCATIONAL INSTITUTIONS ONLY
14. DATE GRADUATED
16. GRADE POINT AVERAGE
17. STRONG SUBJECTS
18. WEAK SUBJECTS
D. REMARKS
19. SIGNATURE
20. POSITION 21. DATE
APPRAISAL OF APPLICANT
NO
13. TO YOUR KNOWLEDGE, HAVE ANY OF THESE
PRIVILEGES EVER BEEN DENIED, REVOKED, OR
VOLUNTARILY RELINQUISHED?
8d. ABILITY TO WORK EFFECTIVELY WITH OTHER
STAFF MEMBERS AND SUPERVISORS
12. TO YOUR KNOWLEDGE HAS THE APPLICANT
EVER HAD CLINICAL PRIVILEGES?
B. FOR EMPLOYERS ONLY
15. RANK IN CLASS
11. TO YOUR KNOWLEDGE, HAS THE APPLICANT
EVER HAD ANY LICENSE REVOKED, SUSPENDED,
DENIED, RESTRICTED LIMITED, OR ISSUED/PLACED
IN A PROBATIONAL STATUS?
9. WOULD YOU REHIRE THIS APPLICANT?
Page 2 of 2
MAY 2006 (R)
FL 10-341a
