Students participating in programs which have a current affiliation agreement with the VA Medical Center, will be permitted learning opportunities. Affiliated institutions (school or college) must verify appropriate student qualifications and credentials to the VA by letter before students may participate in patient care and/or services.

If there is no current affiliation agreement, the institution should contact the appropriate VA Discipline Specific Coordinator to determine appropriateness of affiliation. If an affiliation is deemed appropriate, the institution may apply for affiliation by completing and submitting an affiliation agreement. Once completed, the agreement should be mailed to the Centralized Health Profession Trainee Coordinator:

Jerome Van Ruiswyk, MD
Associate Chief of Staff for Clinical Affairs
VA Medical Center
5000 West National Avenue
Milwaukee, WI  53295

For those faculty associated with affiliated institutions, please comply with the following instructions for faculty and student participation. Substitute faculty must also comply with these procedures and training requirements. Questions should be directed to the VA Discipline Specific Coordinator.

• Step 1: Contact VA Discipline Specific Coordinator to initiate clinical training opportunities.

• Step 2: Faculty Application (applicable to on-site faculty only)

  • If you are an on-site faculty, complete and submit paper copies of the following to your VA Discipline Specific Coordinator:

  • Application for Associated Health Occupations - VA Form 10-2850-C
  • Declaration for Employment OF-306
  • Resume/Curriculum Vitae and list current and expired applicable licenses/certifications
  • Signed Without Compensation (WOC) Appointment Letter (3 copies)
  • Request for Personal Identity Verification (PIV) PIV Form. VA Form 0711 (complete Section 1 only)
  • Completed Security Check forms
    • Special Agreement Check (SAC) Form (Fingerprint Application)
    • National Agency Check with Written Inquiries (NACI) OPM Form 85 (EG) Questionnaire for Non-Sensitive Positions (PDF)
      Note: applicable if facility assignemtn is greater than 6 months
       

• Step 3: Faculty Orientation
  • Read orientation materials
    • "Orientation Handbook"
    • Rules of Behavior (Confidentiality/Privacy and Computer Access Agreement)
       
  • Submit the following to your VA Discipline Specific Coordinator:
    • Signed Acknowledgement of Review referred to in the "Orientation Handbook"
    • Signed Rules of Behavior (Confidentiality/Privacy and Computer Access Agreement) located in the "Orientation Handbook"
    • Signed Statement of Commitment
      Note: On an annual basis, contact the VA Discipline Specific Coordinator for instructions for completion of the hospital wide mandatory and area specific mandatory education.

• Step 4: Procedures for Faculty: Coordinating Student Experiences
  • Coordinate with VA Discipline Specific Coordinator
    • Submit a Trainee Qualifications and Credentials Verification Letter (TCQVL) and  include complete list of student names with full social security numbers.
    • Instruct students that they must report in person to Human Resources for fingerprinting. Two forms of valid identification are required. One form of ID must be a federal or state-issued photo identification.
    • Coordinate issuance of ID badge. Submit completed Request for Personal Identity Verification (PIV) PIV Form. VA Form 0711  (Section 1).
    • Schedule Computerized Patient Record System (CPRS) training (if applicable) and Bar Code Medication Administration (BCMA) training (if applicable)
    • Coordinate completion of area specific orientation.
       
  • Review orientation materials with students:
    • "Orientation Handbook"
    • Rules of Behavior (Confidentiality/Privacy and Computer Access Agreement)

     

  • Obtain from each student and review for accuracy/completeness:
    • Signed Acknowledgement of review of Orientation Handbook
    • Signed Rules of Behavior (Confidentiality/Privacy and Computer Access Agreement)
    • Signed Statement of Commitment
    • Completed Application for Associated Health Occupations - VA Form 10-2850-C
    • Completed Declaration for Employment OF-306
    • Completed Clinical Trainee Registration Form VA Form 10-0410
    • Signed Without Compensation (WOC) Appointment Letter
    • Request for Personal Identity Verification (PIV) PIV Form. VA Form 0711 (Section 1 only) *
    • Security Check:*
      • Special Agreement Check (SAC) Form (Fingerprint Application)
      • In addition to the SAC, complete OPM Form 85 (EG) Questionnaire for Non-Sensitive Positions (PDF) NACI - National Agency Check with Written Inquiries (NACI) -  if facility assignment is greater than 6 months.
        
        *2 valid IDs required: one of which must be a federal or state-issued photo identification, (ie driver's license, passport); 2nd ID must be either birth certificate or social security card; proof of naturalization will be required for all non-US citizens (if applicable).

     

  • Enter completion dates for each activity on the trainee tracking data sheet for student group and submit to Discipline Specific Coordinator with supporting documents, within 3 working days of 1st day clinical experience.
     
  • Upon completion of clinical training:
    • Coordinate student evaluations:
      • Local hardcopy evaluation Clinical Training Evaluation
      • National online evaluation: VA Learners' Perceptions Survey
    • Collect and return all VA ID badges to VA Discipline Specific Coordinator