VA FL 10-341(a) Employment Reference for Title 38 Employee

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

Dear
has applied to the Department of Veterans Affairs for
employment as a

and has given your name or institution

as a reference.
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.
Sincerely yours,

The information you provide on the individual named above will be disclosed to the individual on his or her request.
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 Health Integrity and Protection Data Bank (HIPDB)
or the list of exclusions, which is maintained by Health and Human Services (HHS) Office of Inspector General (OIG) on the List of Excluded
Individuals and Entities (LEIE), 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.
FL 10-341a
MAR 2009

(over)

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OMB No. 2900-0205
Estimated Burden: 30 minutes

APPRAISAL OF APPLICANT
A. APPLICANT INFORMATION
1. NAME OF APPLICANT

2. SOCIAL SECURITY NUMBER

B. FOR EMPLOYERS ONLY
3. HOW LONG HAVE YOU KNOWN THE APPLICANT
PROFESSIONALLY?

4. WHAT HAS BEEN YOUR RELATIONSHIP WITH THE APPLICANT?

5. APPLICANT WAS EMPLOYED
FULL-TIME

7. AVERAGE HOURS APPLICANT WORKED
PER WEEK

6. DATES OF EMPLOYMENT
PART-TIME

FROM

TO

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
8d. ABILITY TO WORK EFFECTIVELY WITH OTHER
STAFF MEMBERS AND SUPERVISORS
8e. DEPENDABILITY
8f. INSTRUCTIONAL SKILLS
8g. ADMINISTRATIVE COMPETENCE
9. WOULD YOU REHIRE THIS APPLICANT?
NO (if "NO,"explain in Remarks)
YES
11. TO YOUR KNOWLEDGE, HAS THE APPLICANT
EVER HAD ANY LICENSE REVOKED, SUSPENDED,
DENIED, RESTRICTED LIMITED, OR ISSUED/PLACED
IN A PROBATIONAL STATUS?
NO (if "YES,"explain in Remarks)
YES

10. REASON APPLICANT LEFT YOUR EMPLOYM ENT

12. TO YOUR KNOWLEDGE HAS THE APPLICANT
EVER HAD CLINICAL PRIVILEGES?
YES

13. TO YOUR KNOWLEDGE, HAVE ANY OF THESE
PRIVILEGES EVER BEEN DENIED, REVOKED, OR
VOLUNTARILY RELINQUISHED?

NO

YES

NO (if ''YES," explain in Remarks)

C. FOR EDUCATIONAL INSTITUTIONS ONLY
14. DATE GRADUATED

15. RANK IN CLASS

16. GRADE POINT AVERAGE

17. STRONG SUBJECTS
18. WEAK SUBJECTS

D. REMARKS

19. SIGNATURE

FL 10-341a
MAR 2009

20. POSITION

21. DATE

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