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The VA Letterhead form is an essential document for students engaging in educational programs at the Robert J. Dole VA Medical Center in Wichita, Kansas. This form outlines the affiliation between the student and the Department of Veterans Affairs, establishing the framework for their experience. Key aspects include the acknowledgment that students will serve without monetary compensation, clarifying their non-employee status. While students will not receive standard employee benefits such as leave or retirement, they may be eligible for certain benefits, which include uniform laundering and quarters subsistence. The form also emphasizes the importance of veteran status, requesting students to indicate their category as it relates to U.S. military service. Under the protections of the Privacy Act of 1974, the information collected about veteran status is intended for statistical and program planning purposes only. Both parties can terminate the agreement at any time by providing written notice, ensuring flexibility and clarity in this professional relationship. Completing this form is a critical step for students to officially commence their association with the VA, enabling them to gain valuable hands-on experience while contributing to the care of veterans.

Va Letterhead Example

DEPARTMENT OF VETERANS AFFAIRS

Robert J. Dole

VA Medical Center

5500 E. Kellogg

Wichita, KS 67218

In Reply Refer To: 589A7/EDU

Robert J. Dole Medical Center

5500 E. Kellogg

Wichita, KS 67218

Dear _______________________:

(Student Name)

Welcome to the Department of Veterans Affairs, Robert J. Dole Medical Center, Wichita, KS.

You will be assigned to our facility as a Student fromthrough, under authority of 38 U.S.C. 7405(a) (1) (D). During your period of affiliation with our facility, you are authorized to perform services as directed by the Service Director(s), Associate Director of Patient Care.

In accepting this assignment, you will receive no monetary compensation and you will not be entitled to those benefits normally given to regularly paid employees of the Department of Veterans Health Administration, such as leave, retirement, etc. You will, however, be eligible to receive benefits indicated below. Cash cannot be paid in lieu of any of these benefits.

Quarters

Subsistence

Uniforms

Launder of uniforms

None

If you agree to these conditions, please fill in the information requested on the reverse side of this document and sign the statement. This agreement may be terminated at any time by either party by written notice of such intent.

Sincerely,

NANCY J. GERSTNER

Human Resources Director

Social Security No:

Date of Birth:

VHA Contact Phone Ext: 57905 VHA Supv/Mentor: Travis Nickelson, RN, BSN

I agree to serve in the above capacity under the conditions indicated. If you agree, sign below.

Veteran Status (Please circle one)

1 - Vietnam Veteran*

2 - Other Veteran

3 - Non-Veteran

*For this purpose, a Vietnam Veteran is one with service between August 5, 1964 and May 7, 1975.

Signature: ______________________________

Date:

Please indicate your veteran status in box at left.

Pursuant to the Privacy Act of 1974, the information about your veteran status is requested under Title 38 United States Code and will be used to help identify veterans status of all VA trainees for statistical and program planning purposes. It will not be used for any other purpose. Disclosure of the information sought is voluntary. Failure to furnish this information will have no adverse effect on any benefits to which you may be entitled.

RCS 10-0161 Report

 

 

 

 

 

 

 

 

 

 

School Affiliation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Program (Place X in box):

 

 

Doctoral

 

Masters

 

BA/BS

 

Associate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certificate

 

 

 

Diploma

 

 

Other (Specify) __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WOC Position Title:

Approximate total hours scheduled to be at VAMC:

Form Characteristics

Fact Name Detail
Form Name VA Letterhead Form
Purpose This form provides information and authorizes students' affiliation with the Robert J. Dole Medical Center.
Governing Laws The form operates under the authority of 38 U.S.C. 7405(a)(1)(D).
Location The form is specific to the Robert J. Dole VA Medical Center in Wichita, Kansas.
Compensation Students receive no monetary compensation during their assignment.
Benefits Students are eligible for certain benefits, including quarters, subsistence, and uniforms.
Termination Clause Either party can terminate the agreement at any time with written notice.
Veteran Status Disclosure The form requests veteran status under the Privacy Act of 1974 for program planning purposes.
Signature Requirement A signature is required from the student to accept the terms and conditions of the assignment.
Contact Information The form includes contact details for the VHA Supv/Mentor and a Human Resources Director.

Guidelines on Utilizing Va Letterhead

Completing the VA Letterhead form requires attention to detail and accuracy. After filling out this form, it must be signed and submitted to the appropriate personnel at the VA Medical Center. This process formalizes your affiliation with the department and confirms your understanding of the terms associated with your placement.

  1. Begin by filling in the Student Name line with your full name.
  2. In the date fields, enter the duration of your affiliation using the format from and to.
  3. Provide your Social Security Number in the designated area.
  4. Input your Date of Birth as requested.
  5. Fill out the VHA Contact Phone Ext with your phone extension, ensuring it is correct.
  6. Identify your VHA Supervisor/Mentor by writing their name, which in this case is Travis Nickelson, RN, BSN.
  7. Sign the form in the area marked for your signature.
  8. Add the current date next to your signature.
  9. Indicate your veteran status by circling the appropriate option on the left side of the form.
  10. Report your School Affiliation by entering the name of your educational institution.
  11. Specify the Type of Program by placing an "X" in the box that matches your educational program.
  12. Fill in the Program Title with the name of your specific program.
  13. Provide the WOC Position Title that you will be serving in during your affiliation.
  14. Estimate and write down the approximate total hours you will be scheduled at the VAMC.

What You Should Know About This Form

What is the purpose of the VA Letterhead form?

The VA Letterhead form serves as an official document from the Department of Veterans Affairs, specifically the Robert J. Dole VA Medical Center. It outlines the terms of assignment for students participating in training or educational programs at the facility. The form confirms the acceptance of the student, the duration of their assignment, and provides important information about the conditions of their service.

Who is required to fill out this form?

This form is intended for students who will be affiliated with the Robert J. Dole VA Medical Center for training purposes. If you are entering a program or placement at this facility, you must complete and sign the form to acknowledge your understanding of the terms, including the lack of monetary compensation and other benefits typically reserved for regular employees.

What benefits will a student receive during their placement?

While students volunteering at the VA Medical Center do not receive monetary compensation or typical employee benefits, they may be eligible for certain non-monetary benefits. These can include access to quarters, subsistence, uniforms, and laundering services for those uniforms. Cash payments in lieu of these benefits are not permitted.

Can the agreement be terminated?

Yes, the agreement outlined in the VA Letterhead form can be terminated by either party. Written notice expressing intent to terminate the agreement must be provided. This provides both students and the VA facility flexibility should circumstances change during the student’s assignment.

What information must I provide on the VA Letterhead form?

Students are required to fill in their personal information, including their Social Security number and date of birth, along with their VA contact person and the name of their supervisor or mentor. Additionally, you will be asked to indicate your veteran status and provide details about your academic program, such as the type and program title.

What does it mean to be classified as a Vietnam Veteran on this form?

The form includes an option for students to identify as a Vietnam Veteran, which is defined as anyone who served between August 5, 1964, and May 7, 1975. This classification is relevant for statistical and program planning purposes and helps the VA identify veterans among trainees.

How is personal information handled according to this form?

The VA Letterhead form incorporates language compliant with the Privacy Act of 1974. It assures students that their personal information, particularly concerning veteran status, is gathered purely for the purpose of identifying veterans in training programs. Disclosure is voluntary, and failure to provide this information will not negatively impact any benefits you may receive.

What should I do if I have questions or concerns regarding the form?

If you have any questions or concerns about the VA Letterhead form or the terms of your placement, it is recommended that you reach out to your assigned contact person or the Human Resources Director at the Robert J. Dole VA Medical Center. They can provide clarity and assist you throughout the process to ensure you understand the terms of your agreement.

Common mistakes

Filling out the VA Letterhead form can seem straightforward, but there are common pitfalls that many make during the process. These mistakes can lead to delays or complications in your application and can sometimes hinder access to important benefits. Understanding these mistakes can help streamline your experience and ensure everything goes smoothly.

One frequent mistake is failing to complete all required fields. It might be tempting to skip sections you believe are unnecessary or irrelevant, but the form has specific requirements for a reason. Omitting information can raise red flags and cause the processing of your application to stall. Take your time to carefully read the instructions and fill in every required space to prevent any unnecessary delays.

Another significant error involves neglecting to provide accurate dates. For instance, if you’re asked to indicate your dates of service, it’s essential to ensure these are correct. An error here could misrepresent your veteran status, potentially affecting your eligibility for certain benefits. Double-checking dates can save you from future headaches.

Many people also overlook the importance of signing the document. It may seem trivial, but forgetting to sign your acceptance agreement can render the form invalid. Whether it’s a physical signature or an electronic one, ensure that you have affixed your name before submitting. This validates your agreement to the terms outlined in the document.

Furthermore, providing inaccurate or incomplete contact information is a mistake that can complicate communications. If the VA needs to reach out regarding your application or benefits, having the wrong phone number or email can create a barrier to obtaining assistance. Always verify that your contact details are correct and up-to-date.

Lastly, many fail to acknowledge the importance of understanding the benefits listed on the form. Knowing what you are eligible for helps in making informed decisions related to your service. Each benefit, from quarters to uniforms, plays a role in your overall experience at the VA. Review these thoroughly to ensure you take full advantage of what’s available to you.

Being aware of these common mistakes can significantly improve your experience with the VA Letterhead form. Take your time, verify your information, and make sure you’re correctly filling out every section. With careful attention to detail, you can help ensure a smoother process in accessing the services and benefits you deserve.

Documents used along the form

The VA Letterhead form serves as an important document for students engaged with the Department of Veterans Affairs. Various other forms often accompany it to ensure proper procedures, benefits, and record-keeping. Below is a list of commonly used forms that might be related to the VA Letterhead form.

  • VA Form 22-1990: This form is used to apply for educational benefits from the VA. It helps determine the eligibility of veterans and service members for tuition assistance.
  • VA Form 22-1995: This is the application form for veterans who want to change their program or place of training. It's necessary to ensure benefits are applied appropriately.
  • VA Form 21-526EZ: Veterans use this streamlined application form to apply for disability compensation. It is crucial for obtaining benefits related to service-connected disabilities.
  • VA Form 21-674: This form is used to apply for benefits for dependents of veterans. It helps to secure educational benefits for eligible family members.
  • VA Form 28-8832: This form is related to the Vocational Rehabilitation and Employment program. It allows veterans to apply for services that help them prepare for, find, or maintain suitable employment.
  • VA Form 10-9052: This document is used to request a change in a student's training program at a VA facility. Keeping this form updated is crucial for ongoing authorization.
  • VA Form 22-5490: This is the form for applying for dependents' educational assistance. It is essential for providing education benefits to children of deceased or permanently disabled veterans.
  • VA Form 10-0143: Used to evaluate whether a facility has the capability to train students or residents, this form is critical for clinical education purposes.
  • VA Form 10-1173: This form documents and certifies the release of medical records for students or trainees within the VA system, ensuring compliance with privacy laws.
  • VA Form 10-2850: This is an application for health professions trainees. It helps collect necessary information from individuals seeking positions within the VA healthcare system.

These forms play key roles in supporting the educational and professional transition for students affiliated with the VA. Completing each document correctly helps ensure a smooth process for obtaining benefits and fulfilling training requirements.

Similar forms

The VA Letterhead form has similarities to several other documents often used in educational or organizational contexts. Each document serves a unique purpose but shares common elements, such as structured information presentation and agreement terms.

  • Internship Agreement: Like the VA Letterhead form, an internship agreement outlines the conditions under which a student or intern will work. It includes details about responsibilities, duration, and lack of monetary compensation.
  • Employment Offer Letter: This document formally extends an offer of employment. Similar to the VA form, it specifies role expectations, benefits, and any conditions that need to be acknowledged.
  • Volunteer Service Agreement: A volunteer service agreement highlights the terms of volunteering, including responsibilities and benefits. Much like the VA Letterhead, it states that no financial compensation will be provided.
  • Clinical Affiliation Agreement: This agreement governs the relationship between educational institutions and clinical sites. It resembles the VA Letterhead in that it outlines student roles, liabilities, and the lack of employee benefits.
  • Student Practicum Agreement: This document details the terms for students undertaking practical experiences. Similarly, it includes conditions of service and acknowledges that students will not receive pay.
  • Training Agreement: A training agreement specifies the terms and conditions for participation in training programs. It closely mirrors the VA Letterhead by setting clear expectations and compensation details.
  • Educational Affiliation Agreement: This type of agreement is established between institutions to facilitate student training. It shares similarities with the VA form in defining roles and confirming the non-compensatory nature of the student’s involvement.

Dos and Don'ts

When filling out the VA Letterhead form, follow these guidelines to ensure your submission is accurate and complete.

  • Do read the entire form carefully before filling it out.
  • Do provide all required personal information, including your Social Security number and date of birth.
  • Do clearly indicate your veteran status by circling the appropriate option.
  • Do sign the form where indicated to confirm your agreement to the terms.
  • Don't leave any sections blank; every field must be completed.
  • Don't use abbreviations or unclear handwriting that might confuse the reader.
  • Don't forget to include your program title and type of program you are affiliated with.
  • Don't submit the form without reviewing it for accuracy and completeness.

Misconceptions

Misconceptions about the VA Letterhead form can lead to confusion. Here are four common myths and the reality behind them:

  • Misconception 1: The form guarantees employment with the VA.
  • This form does not create employment. It merely outlines the terms for a student’s affiliation with the VA for training or experience.

  • Misconception 2: Students will receive financial compensation for their work.
  • No monetary compensation is provided. The form clearly states that students will not receive payment or benefits like regular employees.

  • Misconception 3: Students are entitled to leave and retirement benefits.
  • Just like the previous point, the document emphasizes that there are no benefits typically available to employees, such as leave or retirement plans.

  • Misconception 4: The information collected is not protected.
  • The form includes a note about the Privacy Act of 1974, which ensures that personal information is confidential and used only for specific purposes related to veteran status.

Key takeaways

Filling out and using the VA Letterhead form correctly is essential. Here are some key points to keep in mind:

  • The form is designed for students assigned to the Department of Veterans Affairs.
  • If you agree to the conditions, make sure to complete the requested information accurately.
  • You will not receive monetary compensation for your services at the facility.
  • Benefits you may be eligible for include quarters, subsistence, and uniforms, but cash payments are not allowed.
  • Your agreement can be terminated any time by providing written notice.
  • Indicate your veteran status on the form, as it helps with statistical planning for VA programs.
  • Ensure that you sign and date the document to confirm your acceptance of the terms.
  • Privacy of your information is protected; it is used solely for purposes outlined in the form.

By following these points, you can navigate the process confidently and ensure compliance with VA guidelines.