VA Connecticut Healthcare System
West Haven, CT 06516
Welcome to VACT Healthcare system. We are happy that you will be rotating with us. In an effort to
process your application for residency/fellowship in a timely manner, and to prevent any delay in your
practicing at the VACT Healthcare System. Here are a few things to keep in mind:
1. Please print and submit each page of the application separately
2. Applications that contain unexplained gaps of time from the time you graduated medical
school until the present time will not be processed. All the months and years must be
accounted for on the application. If there is not enough space, please use a separate piece of
paper and attach a copy to your CV.
3. If a question or section doesn’t apply to you, simply put “N/A”. Do not leave anything blank.
Yes or No questions need to be answered.
4. Please note the appointment affidavit (SF61) does not need to be notarized
ST
5. All July 1st appointee’s MUST get fingerprinted by MAY 1 . You can get this done at
VACT Healthcare system or at another VA hospital. (please see optional fingerprint form for
directions) We are not able to get computer codes until this is done and the prints are back. It
takes about 10 days for your fingerprints to come back and then another 4 days for the
approval process for computer access.
For other appointees starting during the academic year you must get fingerprinted at least 30
days prior to the start of your rotation.
You must be fingerprinted at VA hospital and the prints are then transferred to us. For a list of
local facility’s you can go to http://www.va.gov/pivproject/piv_badge_offices.asp
Please note: Your application cannot be processed unless completed!!! Applications take at least
30 days to process. You cannot practice medicine at the VA without your application signed off
by the Facility Designated Education Officer or Designee.
If you have any questions, please contact Liz Castellon at 203-932-5711 x2704 or
Elizabeth.Castellon@va.gov or Michael Sfondrini at 203-932-5711 x2746 or Michael.Sfondrini@va.gov
When you have completed all of the paperwork (including the enclosed checklist) please mail, email
or drop off to:
Nicole Potter, Registrar (who will forward to Liz Castellon at VA)
PO Box 208030
333 Cedar Street
New Haven, CT 06520
DEPARTMENT OF VETERANS AFFAIRS
VA Connecticut Healthcare System
950 Campbell Avenue
West Haven, Connecticut 06510
Dear
Welcome to the Department of Veterans Affairs. You will be assigned to our facility as ____Woc Housestaff___________
from ______________ through ___6/30/19___________ under the authority of 38 U.S.C. 7406. During your period of affiliation with our
facility, you are authorized to perform services as directed by the Chief of Medicine
.
In accepting this assignment you will receive no monetary compensation and will not be entitled to those benefits normally given to regularly
paid employees of the Veterans Health Administration, such as leave, retirement, etc. You will, however, be eligible to receive the benefits
indicated below. Cash cannot be paid in lieu of any of these benefits.

Quarters
 Subsistence

Uniforms
 Laundering of Uniforms
If you agree to these conditions, please sign the statement below and return the letter in the enclosed postage-free envelope. This
agreement may be terminated at any time by either party by written notice of such intent.
Please indicate your veteran status by circling the appropriate number below.
Sincerely yours,
Chief, Human Resources Management Service
Enclosure
-----------------------------------------------------------------------------------------------------------------------------------------------------------------I agree to serve in the above capacity under the conditions indicated.
Veteran Status
Signature ____________________________________
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.
FL 10-294
Date _________________________________________
VACT RESIDENT ADDITIONAL INFORMATION
1. Name:
2. Preferred Email Address:
3. Have you ever used CPRS?
Yes
No
4. Are familiar with and capable of using CPRS without additional training?
Yes
No
5. Do you have a VA TMS Account?
Yes
No
6. Have you updated your training on TMS?
Yes
No
7. I will get fingerprinted at VA Connecticut
Yes
No
8. I will get fingerprint at my local VA hospital
Yes
No
Yes
No
Location___________________________
9. Have you ever had a VA PIV Card?
10. When does the card expire?
11. Which VA issued the PIV card?
**********************************************************************************************
EMERGENCY CONTACTS
Name/phone of person to be contacted in case of emergency:
Name:
Phone:
Relationship
Name/phone of Secondary emergency contact person:
Name:
Phone:
Relationship
Anticipated CT address
(If known)
***USE THIS FORM WHEN GETTING COURTESY FINGERPRINTING DONE***
AT A FACILITY OTHER THAN VA CONNECTICUT HEALTHCARE SYSTEM
Full Name:
______________________________________________
Last
First
Middle
Fingerprinting needs to be completed by MAY 1, 2016
If this is not completed you will not be able to start on July 1st
Bring this form with you to your local Fingerprinting Office
Locate and contact a VA badging/fingerprinting office:
http://www.va.gov/pivproject/piv_badge_offices.asp
Date:
Fingerprint Location:
SOI: VAC5
SON: 1333
REMINDER: NOTIFY YOUR VA SERVICE CONTACT WHERE & WHEN YOU ARE
GETTING PRINTS DONE; CONTACT :
Elizabeth Castellon
Elizabeth.castellon@va.gov
YOU MUST COMPLETE THIS TRAINING AND RETURN THE
CERTIFICATES WITH YOUR PAPERWORK OR YOU WILL NOT GET
COMPUTER ACCESS.
VHA Mandatory Training for Trainees
In order for you to train at VA, you are required to complete a mandatory training program titled VHA
Mandatory Training for Trainees. This training is available through the VA Talent Management
System (TMS). The TMS offers web-based training to VA employees and its partners.
To use the TMS, you must self-enroll and create a profile at http://www.tms.va.gov. Once you are at
the TMS website, follow the steps listed below to create your profile, launch the mandatory training
course and complete the content prior to your coming to VA to begin your clinical training. Items
noted in red should be entered on your profile.
Managed Self-Enrollment (MSE) enhances VA’s training and reporting compliance, and is another
step toward establishing VA as a 21st century organization built on providing the best care and service
possible for our Veterans!
If you have any questions or require additional information, please do not hesitate to contact me at
(203) 932-5711 Ext. 2704. If you need to leave a message, please be sure to leave a contact number
and best time to call. You can also email me with any questions or concerns.
Step-by-Step Instructions
1.
2.
3.
4.
5.
From a computer, launch a web browser and navigate to http://www.tms.va.gov
Click the [Create New User] link located near the SIGN IN button.
Select the radio button for “Health Professions Trainee” DO NOT SELECT "WOC"
Click the [Next] button
Complete all required fields, and any non-required fields if possible.
a. My Account Information:
i. Create Password
ii. Re-enter Password
iii. Security Question
iv. Security Answer
v. Social Security Number* (If you do not have a Social Security Number, follow the onscreen instructions when registering.)
vi. Re-enter Social Security Number
vii. Date of Birth
viii. Legal First Name
ix. Legal Last Name
x. eMail Address (Enter your personal email address. The eMail address will be used as
your UserID when you login)
xi. Re-enter eMail address
xii. Phone Number (Enter a number where you can be reached by VA staff if issues arise
with this self-enrollment process or in other circumstances)
b. My Job Information:
i. VA City – (West Haven)
ii. VA State – (CT or Connecticut)
iii. VA Location Code – (CON(VA Connecticut Healthcare System))
iv. Trainee Type – (Physician Residents)
v. Specialty/Discipline – (Medicine)
vi. VA Point of Contact First Name - (Elizabeth)
vii. VA Point of Contact Last Name - (Castellon)
viii. VA Point of Contact Email (elizabeth.castellon@va.gov)
Once you have entered all of the required data, click the “Submit” button. Your profile will be
immediately created. Copy and save the UserID displayed to you on the confirmation page, as you
will need this for future logons to the VA TMS. Once done, click on the “Continue” button and wait
until your “To-Do” list is displayed with the title of the mandatory training course.
Launching and Completing the Content
1.
2.
3.
4.
5.
Mouse over the title of the VHA Mandatory Training for Trainees training course.
Click the [Go to Content] button in the pop-up window that appears.
Complete the course content following the on-screen instructions.
Exit the course and a completion of the course will be recorded for your effort.
Click on the “Completed Work” pod on the lower right hand side of your internet browser
window.
6. Move your mouse over the title of the course you just completed and choose to “Print
Completion Certificate”.
7. Print your completion certificate and save it in a pdf file for your records.
8. Please provide copy of certificate with application packet.
Trouble-shooting and Assistance
The Check System link on the VA TMS is an automated tool that confirms the existence of basic,
required software on the computer you are using to complete this training. If one of the components of
your computer is not in compliance with the requirements, a red “x’ will appear next to the Check
System link. Should this be the case with your computer, please follow the instructions to bring your
computer up to the standards that will work with the VA TMS.
If you do not have a Social Security Number, or if you experience any difficulty creating a profile or
completing the mandatory content, contact the VA MSE Help Desk at 1.888.501.4917 or via email at
VAMSEHelp@gpworldwide.com.
* Your SSN is used only as a unique identifier in the system to ensure users do not create multiple
profiles. The SSN is stored in a Private Data Table that cannot be accessed anywhere via the VA TMS
interface. It is securely transferred to a VA database table inside the VA firewall where it can be
confirmed, if necessary, by appropriately vested system administrators and/or Help Desk staff.
VA Hospital Application Checklist
VACT Healthcare Center
Medical Service/111
950 Campbell Ave
West Haven, CT 06516
203-932-5711 x 2704
Name:
Please complete and return VACT Healthcare Center’s Application Package which
includes the following documents:

Application for Health Professions Trainees (4 pages)

WOC letter

Declaration for Federal Employment (2 pages) Optional Form 306 rev 10/2011

Appointment Affidavit (1page)

Additional information form

Fingerprinting Authorization form (1 page)

VHA Mandatory Training for Trainees (please attach certificate)
VA Form 10-2850D
Please include a copy of the following documents with the return of your
Application Package:

Curriculum Vitae

Copy of US Passport or Naturalization papers (if Naturalized US Citizen)

Copy of Permanent Residency – Green Card (if applicable)

Copy of employment authorization, J1, H1B, F1, etc. (if applicable)
YOU MUST CHECK ONE AND PROVIDE ALL REQUESTED INFORMATION:
___X__NEW (PAID / WOC- UNPAID):
CODE: INV
______CURRENT (PAID / WOC- UNPAID): CODE PIV
_____CURRENT (PROMOTION / HIGHER SECURITY INVESTIGATON): CODE INV (SON 430H – SOI VAS0)
___EMPLOYEE ___ ATTENDING/PHYSICIAN ___RESIDENT/INTERN/FELLOW ___FEE BASIS ___RESEARCH
___VOLUNTEER __ STUDENT:YALE UNIVERSITY SCHOOL OF MEDICINE END OF PROGRAM DATE_______________
STATION: West Haven / Newington / Vet Center Location_____________ / UCONN / RH Vets Home & Hospital
The following information is required in order to submit your fingerprints, which will be taken by Human Resources as a
part of processing your appointment or in connection with the reinvestigation required due to the risk level associated
with your position or reissuance of your badge.
PERSONAL EMAIL ADDRESS: _____________________________
__________________
PERSONAL: SERVICE WORKING OR ROTATING IN___Medicine_ POSITION TITLE:_INTERN/RESIDENT/FELLOW
(Residents must enter the practice, for example: Medicine, Psychology, Surgery Neurology, etc…)
NAME (Full Name): __________________________________________________________________
LAST
FIRST
LEGAL MIDDLE NAME ON BIRTH CERTIFICATE
ALIASES: _______________________________________________________ PHONE #_________________________
MAIDEN NAME, DIVORCED NAMES, LEGAL NAME AT BIRTH, ETC.
VA OFFICE, CELL PHONE
SSN (full):________________________________________DOB:_____________________________________________
CURRENT HOME ADDRESS:___________________________________________________________________________
COMPLETE STREET ADDRESS (Include Apt #, Suite #, etc.), CITY STATE ZIP
COUNTRY OF CITIZENSHIP: US CITIZEN: [ ] YES
[ ] NO IF NO – COUNTRY OF CITIZENSHIP________________
PLACE OF BIRTH (CITY WHERE HOSPITAL IS THAT YOU WERE BORN AT)
USA: CITY_____________________________________STATE________________________________________________
OUTSIDE USA: _______________________________________________________________________________________
CITY/TOWN/VILLAGE/TERRITORY/PROVINCE
COUNTRY
PHYSICAL (CIRCLE ONE ONLY): GENDER: MALE / FEMALE
RACE: A-ASIAN
B-BLACK
I-NATIVE AMERICAN
W-CAUCASIAN/LATINO
U-UNKNOWN
EYES: BLU-BLUE, BRO-BROWN, GRN–GREEN, GRY–GRAY, HAZ–HAZEL, PNK–PINK, MAR–MAROON,
MUL–MULTICOLORED, XXX-UNKNOWN
HAIR: BAL-BALD, BLK–BLACK, BLN-BLONDE/STRAWBERRY, BLU-BLUE, BRO-BROWN, GRN-GREEN, GRYGRAY/PARTIALLY, ONG-ORANGE, PLE-PURPLE, PNK-PINK, RED–RED/AUBURN, SDY–SANDY, WHI–WHITE,
XXX-UN KNOWN
HEIGHT:
(FEET/INCHES)
WEIGHT:
(POUNDS)