VA Health Professions Trainee Data Collection Form

Submit the completed form along with any required documents to the VA training facility where you are applying. You can mail the form to the physical address provided by the facility, fax it to the designated fax number, or use the online submission form if available. Contact the facility directly for specific instructions and submission details. In addition, make sure to keep a copy of the completed form for your records. Advice: Double-check all information for accuracy before submitting to ensure no delays in processing.

May 31, 2026: Expiration date for the current version of the form.

The VA Health Professions Trainee Data Collection Form is essential for capturing the eligibility details of trainees applying to clinical training programs offered by the Department of Veterans Affairs. This form ensures that all required personal, educational, and professional information is accurately documented, making it easier for the VA to evaluate and approve the trainee's application. The form consists of several sections, each focusing on different aspects of the trainee's application process. These sections include personal information, military duty status, citizenship status, licensure, certification or registration, education and training details, and additional questions concerning professional conduct and qualifications. The designated education officer or designee is responsible for verifying the trainee's credentials and approving their appointment. Submitting a complete and accurate form is crucial for the timely processing of the trainee's application. Failure to provide all necessary information or meet the outlined criteria may result in delays or denial of the application. Therefore, it is vital to carefully review and complete each section of the form, ensuring that all required documentation is included.

• 1. Applicant Information: Includes fields for name, address, contact details, social security number, email addresses, date of birth, and training facility details.
• 2. U.S. Military Duty Status: Captures information about the trainee's military service and branch of service, including reserve or National Guard status.
• 3. Citizenship: Requires details about the trainee's citizenship status, including providing immigration or visa information if applicable.
• 4. License, Certification, or Registration in Current Clinical Profession: Lists all current licenses, certifications, and registrations, including DEA.
• 5. License, Certification, or Registration in Other/Previous Clinical Professions: Captures information about previous or other licenses, certifications, and registrations held by the trainee.
• 6. Education and Training After High School: Includes fields for documenting education and training details post-high school, including institution names, addresses, and dates.
• 7. Graduates of an International Medical School: Specifics for international medical school graduates, including ECFMG certification details.
• 8. Internship, Residency, and Fellowship Training: Documentation of details for internship, residency, and fellowship training programs completed by the trainee.
• 9. Additional Questions: Includes questions regarding professional conduct, malpractice, and involvement in Medicare and Medicaid programs.
• 10. Remarks: An additional section for providing any necessary comments or explanations related to the information on the form.

Failure to submit this form can result in delays or denial of your application for VA clinical training programs. It is important to accurately complete and promptly submit the form to avoid any negative consequences.

• Application Delay: Your application may be delayed if the form is not submitted on time, affecting your training schedule.
• Denial of Application: Incomplete or missing forms can result in the denial of your application, preventing you from participating in the training program.
• Incomplete Records: Failure to submit the form may result in your records being incomplete, potentially impacting future applications or evaluations.

• 1. Applying for VA Training: Use the form when you are applying for a clinical training program offered by the Department of Veterans Affairs.
• 2. Updating Information: Complete the form to provide updated personal, educational, and professional information to the VA.
• 3. Documenting Military Service: Use the form to document your military duty status and branch of service, if applicable.
• 4. Providing Citizenship Details: Provide necessary citizenship and visa information when required, especially if you are not a U.S. citizen.
• 5. Listing Licensure and Certification: Use the form to list all licenses, certifications, and registrations, including DEA.