Memorandum
From:
Research Staffing Section Director
Subj:
VASDHS Research WOC Application Packet
To:
Applicant
Hello,
You are receiving this packet because you would like to participate in a VA Research Project. A condition of
that participation is that you must have a Without Compensation (WOC) appointment with Research Service.
You may not begin work until your appointment is approved and your training is complete.
Please complete this packet as soon as possible so that we can clear you to begin your research work quickly.
Complete the packet on the computer to avoid mistakes due to misinterpretation of handwriting.
Once you have filled out the packet print it for your PI/supervisor to review it and sign where necessary. Areas
that require your signature will be highlighted in yellow, areas that require your PI/supervisor’s signature will be
highlighted in blue.
All items on the attached checklist must be completed before you submit your packet. If all items are not
completed then we cannot accept your packet.
Please bring all of the completed forms to the Research Staffing Section in the Main VA Hospital Building,
Research Admin Office, 6th floor Room 6002. Robert Atienza is the primary point of contact however either
Debbie Lynn or I can accept your packet if Robert is not available.
NOTE: If your packet is incomplete or needs corrections you and your PI will be notified via e-mail and no
further action will be taken with your packet until the appropriate forms are corrected or received.
What Happens Next: For individuals with a 6 month appointment or less your appointment can now be
processed and you will receive an e-mail regarding your training. For those with appointments over 6 months
you will be enrolled and sent instructions for the background investigation. We CANNOT process your
appointment without the background investigation being completed.
We are no longer reviewing packets when you drop them off so it is imperative you ensure all items are
completed according to the checklist on the next page and you bring your required identification to
avoid delays in processing your appointment.
Regards,
Coral Ana
Research Staffing Section Director
VA Research WOC Appointment Application Checklist
Instructions for Required Forms (all included in this packet)
Employee Contact and Work Information – Please complete, sign & date
Job Title – please check a box that best describes your work at the VA (only items on this sheet may be
used as research job titles!)
Scope of Practice for Research – complete, sign & date
Research List of Non-Clinical Position Duties – complete if applicable
Research List of Clinical Position Duties – complete if applicable
Emergency Contact Information – read, complete, sign & date
Intellectual Property Agreement – read, complete, sign & date
Employee Health Form for PPD (Tuberculosis Surveillance) – follow instructions on form
NOTE: This must be completed BEFORE you turn in your packet.
Fingerprint Request & Verification Form – follow instructions on form
NOTE: This must be completed BEFORE you turn in your packet.
PIV Badge Request Form - complete
Annual Work Associated Hazards Assessment – complete with PI & sign
These forms will show up in a reading pane when you open this PDF packet.
Declaration for Federal Employment (OF 306)
Form I-9: Employment Eligibility Verification – must bring identification (Driver’s License AND Social
Security card OR Passport)
Resume – must have! Go to www.usajobs.gov and use the resume builder if you do not have one.
TIPS
•
This is an auto-fill PDF. Type in a field and hit enter and identical fields will be automatically filled in for you.
•
You can digitally sign this packet if you have PKI (public key infrastructure).
•
DO NOT PRINT DOUBLE SIDED PLEASE!
Points of Contact
•
Robert Atienza, Research Staffing Intake
Coordinator (858) 552-8585 x1159 /
roberto.atienza@va.gov
•
Debbie Lynn, Research Staffing Compliance Associate
(858) 552-8585 x2505 / Email: deborah.s.lynn@va.gov
•
Coral Ana, Research Staffing Section Director
Phone (858) 552-8585 x5980 / Email: coralyn.ana@va.gov
WOC Employee Contact and Work Information
Please ask your Principal Investigator to assist you in completing this page
Date:
Research Staff Name:________________________
PI:______________________________________
PIace of Birth:
Date of Birth:
Position Title:
Paid by:
Service:
UCSD
VMRF
Other):
Mail Code:
Room #:
SSN#:
Work Email (if none, please provide personal email address):
Lab Phone:
Office Phone:
Home Phone:
Home Address:
Mailing Address
City
State
Zip
---------------------------------------------------------------------------------------------------------------------------------------------------------Work Schedule:
Full-time (40 hours)
Work Days:
S
Part-time (
M
T
W
hours)
Th
F
Student:
S
Y
N
AM to
Work Hours:
PM
Transportation Method: (i.e., car, carpool, coaster, bus, etc.)
Please be advised that parking is limited at the VA and you may not qualify for parking privileges at the VA.
---------------------------------------------------------------------------------------------------------------------------------------------------------Are you a licensed healthcare provider:
Yes (please provide photocopy)
No
Expiration Date:
License #:
---------------------------------------------------------------------------------------------------------------------------------------------------------How long do you plan to work in this position?
6 Months
1 Year
2 Years
----------------------------------------------------------------------------------------------------------------------------------------------------------
I understand that (1) this employee will not begin work until all paperwork has been approved; (2) that I am responsible
for notifying Research Admin when this WOC employee terminates; and (3) that this WOC employee will complete all of
the necessary training to complete his/her duties that he/she has been assigned and that documentation is submitted
to Research Admin office and all training remains current.
P.I. Signature
Date
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Scope of Practice for Research for NON-PI
Renewal
Name:
Research Job Title:
Email Address:
Phone:
Principal Investigator (PI): ____________________________
Primary Supervisor (if not PI): ____________________________
Additional supervising PIs or alternate supervisors with same VA clinical privileges as PI: _______________________ /
EDUCATION
Education
Undergraduate
Graduate
Doctoral
Degree
Institution
Degree Field
Specialty
Clinical License #: _________________ State: __________ Country: ___________________
Discipline of License :
*Psychology Only:
MD
Nursing
Psychology
Resp. Therapy
Social Work
N/A
Date Rcvd (Or Projected)
Not Applicable
Other: _____________
APA-accredited PhD Program
APA-accredited Internship – Institution:___________________
Training Program
Requests for Appointment in this category must be accompanied by TQCVL or RCVL list confirmation
Participating in a Formal Clinical Training Program through the VA (managed by Education Service)?
No
Yes
Start Date: _________ Planned Date of Completion: __________ Supervisor (if other than PI): _____________________
CLINICAL TRAINING PROGRAM (check one):
Medical Student
Student Resident
Clinical MS/PhD Post-Doctoral Trainee
Clinical MS/PhD Student
Fellow
Other (specify): ________________
The Scope of Practice is specific to the duties and responsibilities of research personnel as an agent of the listed Principal Investigator
(PI) and/or alternate supervisor. As such he/she is specifically authorized to conduct research with the responsibilities outlined below.
The supervisor must complete, sign and date this Scope of Practice. Research staff performing clinical care as part of research or
performing research activities that may be considered clinical care must also be credentialed and privileged or have a scope of practice
validated through a clinical service.
PI Not
Approved
PI
Approved
NATURE OF DUTY
Staff
Requested
RESEARCH PROCEDURES: Research staff may be authorized to perform the following duties/procedures on a regular and ongoing
basis. Research staff should initial boxes to identify and request specific job duties where appropriate. PI must initial where job duty is
approved or denied. Research staff (employee) and PI initials indicate they are aware and agree to maintain current status of
role-specific training as itemized below, and that Human, Animal, or Bench Research duties may ONLY be performed on
active Human, Animal, or Bench Protocols with current approval by the VASDHS R&D Committee and applicable
Subcommittee(s).
ACOS R&D Approval
Special Conditions
YES
NO
Research Preparatory Duties: Does Not Require Employee to Be on Active Protocol/Project Staff List
Not Requested
Initiates submission of regulatory documents to IRB,
IACUC, VA R&D committee and others (VMRF, FDA,
IRC, etc).
Page 1 of 5
PI Not
Approved
PI
Approved
NATURE OF DUTY
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Staff
Requested
VA San Diego Healthcare System (664)
ACOS R&D Approval
Special Conditions
YES
NO
Human Subjects Research Duties: Performed ONLY on Active VASDHS Human Subjects Protocol on which
Employee is Listed as Staff
Not Requested
Accesses, records, or analyzes sensitive subject
information while maintaining confidentiality.
Maintains complete and accurate data collection for
case report forms and source documents
(Non-subject contact) – requires HRPP & GCP,
Privacy & HIPAA Training
Provides education regarding study activities, or
provides screening forms or documents to subjects
and assists in completion without performing
assessment activity. (Subject contact) – requires
HRPP & GCP, Privacy & HIPAA, and Suicide
Prevention Training
Obtains informed consent from research subject,
documents consent in research subject’s medical
record if applicable. (Subject contact) – requires
HRPP & GCP, Privacy & HIPAA, and Suicide
Prevention Training
Documents study activities in CPRS– requires
HRPP & GCP, Privacy & HIPAA Training
Provides education and instruction of study
medication use, administration, storage, and side
effects, and notifies appropriate parties regarding
adverse drug reactions– requires HRPP & GCP,
Privacy/HIPAA, and Suicide Prevention Training
Schedules subjects using VistA or CPRS –requires
VistA Scheduler training
Performs venipuncture to obtain specimens required
by study protocol * Attach phlebotomy certificate*
(VA privileged clinicians do NOTselect this duty,
request Clinical Intervention Duty below). –
requires HRPP & GCP, Privacy & HIPAA, &
Suicide Prevention Training
Administers questionnaires, surveys, Mental Health
instruments, or other assessment tools without
clinical interpretation, diagnosis, intervention, or
treatment. – requires HRPP & GCP, Privacy &
HIPAA, and Suicide Prevention Training
Clinical Interventions Including Diagnosis, Interpretation, or Treatment: Performed ONLY on Active VASDHS
Human Subjects Protocol on which Employee is Listed as Staff
Not Requested
Full (not limited) clinical privileges or functional statement/clinical scope of practice required from appropriate clinical service. If clinical
service has granted only limited privileges, then do not select Clinical Intervention Duty below, instead use “other duties” on next page
to specify what limited clinical duties are being requested. Research Service does not approve clinical privileges but will confirm
existing privileges prior to approving any duties in this category.
Physician-Specific
Nursing-Specific
Psychology-Specific
Other: Describe
Page 2 of 5
PI Not
Approved
PI
Approved
NATURE OF DUTY
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Staff
Requested
VA San Diego Healthcare System (664)
ACOS R&D Approval
Special Conditions
YES
NO
Animal Research Duties: Performed ONLY on Active VASDHS Animal Subjects Protocol on which Employee is
Listed as Staff
Not Requested
Animal Care, procedures, or surgery
(as described on attached form) – requires
Biosecurity, Biosafety, VMU Orientation, Working
with the VA IACUC, and if applicable Waste
Anesthetic Gases and species specific training
designated by assigned protocol.
Laboratory Bench Research Duties: Performed ONLY on Active VASDHS R&D Project with Bench Research
Component on which Employee is Listed as Staff
Not Requested
Bench Research duties (specify on attached form)
– requires Biosafety and Biosecurity Training
Works with de-identified human specimens (does
NOT require HRPP & GCP training)
Works with identifiable human specimens – requires
HRPP & GCP, Privacy & HIPAA Training
TO BE COMPLETED BY THE RESEARCH ADMIN OFFICE:
Required Role Specific Training for ANY Human Subject Duties or Human Specimens:
VA Human Subjects Protection and Good Clinical Practices (HRPP & GCP)
Required Additional Training for Human Subjects Contact Duties:
Suicide Prevention
Required Additional Training for Patient Scheduling Duties:
VHA Scheduling, Electronic Wait List (EWL)
Required Training for Animal Research Duties:
VMU Animal Orientation
Working with the VA IACUC
Waste Anesthetic Gases (WAG)
Required Training for Laboratory Bench Work:
Biosecurity
Biosafety
Signature of Research Staff (employee)
PI Not
Approved
PI
Approved
Mr./ Ms.
is authorized to perform the following miscellaneous
duties not otherwise specified in this Scope of
Practice.
Staff
Requested
OTHER DUTIES (describe): ACOS R&D to Note Under Special Conditions If Duty Requires Employee to Be on
Staff List of Active Protocol/Project
Not Requested
ACOS R&D Approval
Special Conditions
YES
NO
Date
Page 3 of 5
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
PRINCIPAL INVESTIGATOR STATEMENT:
This research Scope of Practice was reviewed and discussed with __________________________ on_____________.
After reviewing education, competencies, qualifications, research practice involving human subjects, and individual skills
as appropriate, I certify that he/she possesses the skills to safely perform the aforementioned duties/procedures. I am
familiar with all duties/procedures granted to this employee in this Scope of Practice. The research staff (employee) and I
agree to abide by the parameters of this Scope of Practice, all-applicable hospital policies and research related
regulations.
I understand that (1) this employee will not begin work until all paperwork has been approved and the employee has
been added to appropriate protocol/project staff lists as applicable to the category(s) of duties; (2) that I am
responsible for notifying Research Admin Office when this employee terminates, (3) that this employee will receive all of
the necessary training to complete his/her duties that he/she has been assigned and that documentation is on file in my
office and copies submitted to Research Admin Office, and (4) I will ensure this employee completes all recurring training
requirements prior to required renewal dates and will monitor their training status.
Principal Investigator/ Supervisor
Date
CLINICAL SERVICE APPROVAL (applicable if clinical duties requested on Research Scope of Practice)
Licensed Practitioners Operating under Approved Privileges (Medical Staff Office):
Full Clinical Privileges (check appropriate boxÆ):
Already Privileged
In Process
Limited Clinical Privileges (check appropriate box Æ & identify Responsible Clinician):
Already Privileged
In Process
ÆResponsible Privileged Clinician who will review/monitor/co-sign all clinical activities:____________________________
Licensed Clinical Staff Operating under Clinical Scope of Practice/Functional Statement:
Full Authority to Act Under License/Scope Issued by Clinical Service (check appropriate Æ):
Approved
In Process
Limited Authority to Act Under License/Scope Issued by Clinical Service (check appropriate Æ):
Approved
In Process
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ______________________________
Unlicensed Staff/Trainees Permitted Limited Clinical Duties Under Supervision:
Unlicensed Professional working towards licensure (as permitted by specific VHA Policy and/or VASDHS Medical Center Policy)
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ____________________________
Trainee on RCVL or TQCVL List (processed as trainee through Education Service)
ÆResponsible Clinician who will review/monitor/sign all clinical activities: ____________________________
Not authorized for clinical duties at VASDHS: Research Scope of Practice must not include duties requiring licensure or Clinical
Scope of Practice, and ID Badge / lab coat must not imply clinical credentials
Signature of Clinical Service / Section Chief
Date
Name of Service / Section
I have discussed my role with the Clinical Service Chief and agree to take responsibility for review and sign-off of all clinical
interventions by this employee.
Responsible clinician concurrence signature:
Not Applicable
============================================================================================
Page 4 of 5
VA San Diego Healthcare System (664)
Scope of Practice for Research Service (Non-PI)
Revision Date: 5/16/2013
Research Admin OFFICE USE ONLY:
Eligible for licensure by education and training
Yes
No
Education Verification
Yes/Valid Thru: ________
No
Not Applicable
Privileges or License Verification
Yes/Valid Thru: ________
No
Not Applicable
Clinical Training Program Confirmation (RCVL or TQCVL)
Yes/Valid Thru: ________
No
Not Applicable
Program: ___________________________
Research Admin Office Review
Date
============================================================================================
Associate Chief of Staff R&D Review:
Approved (check as appropriate below for any conditions of approval)
Current Clinical Privileges must be maintained at all times (attach copy of privileges to this scope)
Current Credentialing as a Non-LIP must be maintained at all times (attach copy of current appointment)
Current Clinical License must be maintained at all times (attach copy of clinical license to this scope)
Current Certification of Competency must be on file and attached to this scope
Verification of Education required (attach evidence of completion to this scope)
Must maintain active trainee status with VASDHS Education Service to perform clinical duties permitted on this
Research Scope; termination of trainee status would require issuance of privileges in order to maintain clinical
duties
Limited Privileges or Limited Clinical Scope of Practice requires review and co-signature of all clinical
assessments, diagnosis, treatment, or intervention by Responsible Clinician identified by Clinical Service Chief on
prior page
Limited authority to function as Unlicensed Professional working towards clinical licensure under
Medical Center Policy; requires review and co-signature of all clinical assessments, diagnosis, treatment, or
intervention by Responsible Clinician identified by Clinical Service Chief on prior page
Licensed Professional hired to fulfill duties that do not require licensure/privileges; per communication from Office
of Quality and Safety, Director of Credentialing and Privileging, dated April 22, 2012, VetPro Credentialing is NOT
required. Employee MUST NOT present to subjects as a licensed, certified, or privileged clinician,
and MUST NOT wear lab coat or ID badge indicating clinical training
Foreign Medical Graduate, does not require VetPro Credentialing but MUST NOT present to subjects as a
clinician, and MUST NOT wear lab coat or ID badge indicating clinical training
Not authorized to perform ANY duties that require clinical licensure, privileges, or certification;
Other (specify): ______________________________________________________________________________
Approved pending VetPro Credentialing:
As Licensed Independent Practitioner (LIP) through Medical Staff Office
Full Clinical Privileges as indicated by Clinical Service/Section Chief Above
Limited Clinical Privileges as indicated by Clinical Service/Section Chief; any clinical duties listed on this
Research Scope require monitoring and sign-off by responsible clinician specified above.
As non-LIP through Human Resources
Full Authority to work under Clinical Scope of Practice as non-LIP as indicated by Clinical Service Chief
above.
Limited Authority to perform duties specified on this Research Scope of Practice as non-LIP as indicated
by Clinical Service Chief above; any clinical duties listed on this Research Scope require
monitoring and sign-off by responsible clinician specified above.
Disapproved (state reason) __________________________________________________________________________________
Identify frequency of Scope Review if required by ACOS R&D:
Annual Scope Review--Scope Includes Clinical Duties
Review by ____________________
Date
(projected change in clinical status requires review earlier than annual)
Subject to 10% Annual Quality Assurance Review of Scopes with non-clinical Human Subjects Research duties
Not Applicable: Scope does not include ANY Human Subjects Research duties
Gerhard Schulteis, PhD.
ACOS R&D
Date
Page 5 of 5
LIST OF LABORATORY POSITION DUTIES
NOT APPLICABLE
Date:
Research Staff Name:
PI:
Co-Investigator:___________________________________
In this position the employee will be working as (Job Title)
be required to perform the following tasks on a regular basis:
ANIMAL CARE
Handling and restraining:
Monkeys
Mice and rats
Rabbits
Invertebrates
Other animals
Feeding
Cleaning cages
Assisting in veterinary procedures
Cats
Dogs
Breeding
ANIMAL SURGERY
Preparation for sterile surgery
Assist in sterile procedure
Endotrachial intubation and use of ventilators
Administration of anesthesia
Emergency medical/surgical procedures
Administration of medication
Venous
Intraperitoneal
Subcutaneous
Tumor implantation into small animals
Animal autopsy
Microsurgery
Catheterization/infusion of small animal arteries
Collection of blood
Post-surgery care
MICROBIOLOGY-BACTERIOLOGY
Maintenance of cultures
solation and purification
Determination of concentration by
Direct colony counting
Antibody titer
Direct microscopic observation
Infectivity assay
Inoculation
Media preparation
Preparation and assay of bacteriophage lysates
Plate pouring
MICROBIOLOGY / VIROLOGY
Fluorescent stains
Reverse transcriptase
Serological tests
Hemagglutination inhibition
Complement fixation
Neutralization
RIA
Virus identification
Cytopathic effect
Hemadsoprtion
Nterferon production
Other:
TISSUE CULTURE
Maintenance and division of continuous lines
Establish primary cell lines
Screening for mycoplasma contamination
Isolation of cell mutants
Cell fusion
Cell hybridization
Staining Cells
Cell cloning
P3 lab precautions
Protein and DNA synthesis assays
, and will
GENETICS
Mutagenisis
Mutation tests
Transduction
Conjugation
Maintenance and breeding of drosophila
Transformation
Extraction of plasmid DNA
Isolation of plasmid DNA
Antibiotic resistance tests
BIOCHEMISTRY
Cell fractionation
Homogenization
Sonication
Differential centrifugation
Purification / Characterization of:
Enzymes
Protein
Phosphate
Nucleic Acids
RNA
Glycoproteins
Other
___________________________________________
Gradients
Density
Other
Equilibrium
Assays
Enzyme
Protein
DNA
Phosphate
Receptor binding
Competitive binding
Other:
Electrophoresis
Immuno
Acrylamide gel
Columns
Paper
Agarose
Isolectric focusing
2 dimension gels
Ficoll
___
___
RNA
Lipids
___
___
Slabs
Chromatography
Paper
Thin layer
Affinity
Column
High pressure liquid
Ion exchange resins
Gas-liquid
Immuno-precipitin techniques
In vitro synthesis of:
Peptides
DNA
RNA
DNA shearing
Other
___________________________________________
ELECTRON MICROSCOPY
Staining
Embedding
Sectioning
Operation of TEM
SEM
Grid preparation
Measuring molecules
Shadowing
Freeze fracture
Diffusion technique of DNA spreading
RADIOBIOLOGIAL
Bioassays of radioactive isotopes
Radioimmunoassays of steroids
Radiosotope handling
Irradiation of tumors in vitro
Radioactive labeling
Other:
GENERAL LABORATORY TECHNIQUES
Pipetting
Weighting
Sterilizing
Titration
Filtering techniques
Glassware washing
Autoclave
Steam and gas
Reagent and buffer preparation
Sterile technique
ELECTRONICS EQUIPMENT
Design
Construction
Troubleshooting
Maintain/calibrate
IMMUNOLOGY
Plaque assay for antibody forming cells
Hemagglutination and hemolysis assay
Fluorescent antibody technique
Spectrofluorometry
Lyophilization
Microhemagglutination
Virus isolation
Antibody titration
HLA typing
E-rosette assay
Plate binding assay
Making antibodies in animals
Making monoclonal antibodies
HISTOLOGY
Perfusion of animals
Fixation of tissue
Processing and embedding in:
Paraffin
Celloidin
Gelatin
Paraffin sectioning of:
Biopsy tissue
Autopsy tissue
Animal tissue
Neurologic tissue
Serial sectioning
Decalcification
Staining methods:
Routine hematoxylin and eosin
Special stains
Metallic impregnation
Histochemical
Autoradiography of tissue sections
Microtomes:
Rotary
Sliding
BIOCHEMICAL INSTRUMENTS
Autoanalyzer
Microburet
Fluorometer
pH meter
Spectrophotometers:
Gamma
UV
Visible
Colorimotor
ESR
Recording
Atomic absorption
Scintillation counter
Fraction collectors
Freeze dryer
Refractometer
Centrifuges:
Standard
High Speed
Model L Preparative Ultracentrifuge
Model E Analytical Ultracentrifuge
OTHER INSTRUMENTS
Incubators
Darkroom equipment
Volumetric glassware
Precision balance
Oscillograph
Blood gas analyzer
Hemocytometer
Plaque counter
Micropipetting equipment
Densitometer
Automatic Dispenser
Particle counter
Gamma counter
Microphotographic equipment
DATA PROCESSING ANALYSIS
Systems programming
Operation of computer systems
High level programming on large computers
Desk-top calculators
Work with programmer
Numerical calculations involving
chemical stoichiometry
Statistics
Cryostat
PHYSIOLOGY
Preparation of chronic animals
Stereotaxic implantation of electrodes/cannulae
Preparation of acute animals
EEG recording
EKG recording
Electrode fabrication:
Intracellular
Extracellular
Preparation of brain slices for in vitro recording
COMPUTER LANGUAGES
List:
PHOTOGRAPHY
Black/white processing
Black/white printing
Color processing
Color printing
Line negative printing
Continuous tone printing
Internegative printing / processing
Transparencies
PLEASE CHECK A JOB TITLE THAT BEST
DESCRIBES YOUR WORK AT THE VA.
Date:
Research Staff Name:
PI:
Co-Investigator:
**NOTE: ALL CLERICAL POSITIONS ARE TITLED**
“RESEARCH ASSISTANT”
List of Position Duties
Biological Science Aide
Research Biologist/Biologist
Biological Science Lab Technician
Research Biomedical Engineer
Biomedical Engineer
Research Chemist
Biomedical Technician
Research Health Science Specialist
Research Assistant**
Research Health Scientist
Clinical Nurse Specialist
Research Microbiologist
Clinical Research Psychologist
Research Pharmacologist
Computer Programmer
Research Physiologist
Computer Programmer Analyst
Research Psychologist
Computer Scientist
Research Speech Pathologist
Electronics Technician
Statistician
Social Science Technician
Research Pharmacist
Nurse Researcher
Veterinarian
Physical Science Technician
Psychologist
Psychology Aide
Psychology Technician
Clinical Research Assistant
Maintenance
IN CASE OF A MEDICAL EMERGENCY
WHAT TO DO IF YOU ARE INJURED ON VA PROPERTY
1. In case of a medical emergency involving respiratory distress or unconsciousness here in the VA San Diego
Healthcare System (VASDHS), have someone call x3333 and report a Code Blue. For all other medical
emergencies requiring assistance call the Emergency Department at x3386.
2. Immediately report the injury to the principal investigator, office manager, or co-worker.
3. If you are able to walk, but need medical assistance, proceed to Employee Health on the 1st floor, room #
1211 and be seen by the doctor. Follow all instructions given to you by Employee Health.
4. If you elect to see your own doctor, get the proper forms from nurse in employee health and follow the
instructions.
5. If you are a VA Paid Employee, as soon as you are able, see Yolanda Castro in Research Administration on
the 6th floor, Room# 6004 to complete the Occupational Workers Compensation Program (OWCP) forms.
6. If you are a UCSD Paid employee, you will need to notify your UCSD HR.
7. If you are a VMRF Paid employee, you will need to notify VMRF at x7606.
8. If your injury is to the extent where you are admitted to the Emergency Department (ED) here at the
VASDHS, please remember that you may be liable for the expenses that are not covered by your respective
medical insurance company. Many times the person may be admitted to the ED, but then will be transported
to the hospital of choice by your insurance company. It is up to your medical insurance provider to make that
decision so you need to contact them as soon as possible. If you are not able to do so, then you need to
have a family member or friend contact your insurance company for you.
9. If you have any questions please call Yolanda at x7014 or come and see her in room 6004.
Check All Boxes that Apply:
Veteran
UCSD-Paid
VA-Paid
VMRF-Paid
Person to contact in case of an emergency:
Printed First & Last Name
Street Address
Phone Number
City
State
Employee Signature
Date
I have read this statement.
Printed First & Last Name
VA-WOC APPOINTEE INTELLECTUAL PROPERTY AGREEMENT
This agreement is made between
and the Department of
Veterans Affairs (VA) in consideration of my without compensation (WOC) appointment at the VA San Diego
Healthcare System at San Diego, California (VASDHS) and performing VA-Approved Research (as defined
below) utilizing VA resources. This agreement is not intended to be executed by WOC appointees
exclusively performing clinical services, attending services, or educational activities at the VAMC.
1.
I hold a WOC appointment at the VAMC for the purpose of performing research projects, evaluated and
approved by the VA Research and Development Committee (VA-Approved Research), at VASDHS.
2.
By signing this agreement, I understand that, except as provided herein, I am adding no employment
obligations to the VA beyond those created when I executed the WOC appointment.
3.
I have read and understand the VHA Intellectual Property Handbook 1200.18 (Handbook) available at
www.vard.org/tts/ip.htm, which provides guidance and instruction regarding invention disclosures,
patenting and the transfer of new scientific discoveries.
4.
UCSD
other:
, I will
Notwithstanding that I am an employee or appointee at VMRF
disclose to VA any invention that I make while acting within my VA-WOC appointment in the
performance of VA-Approved Research utilizing VA resources at the VASDHS or in VA-approved
space.
5.
I understand that the VA Office of General Counsel (OGC) will review the invention disclosure and will
decide whether VA can and will assert an ownership interest. Every effort will be made to issue a
decision within 40 days of receipt of a complete file. OGC will base its decision on whether VA has
made a significant contribution to the invention, to include my use of VA facilities, VA equipment, VA
materials, VA supplies, and VA personnel, as well as assessment of the potential of the invention.
6.
If VA asserts an ownership interest based on my inventive contribution, then, subject to Paragraph 7
below, I agree to assign certain ownership rights I may have in such invention to the VA. I agree to
cooperate with VA, when requested, in drafting the patent application(s) for such invention and will
thereafter sign any documents, recognizing VA’s ownership, as required by the U.S. Patent and
Trademark Office at the time the patent application is filed.
7.
VA recognizes that I am employed or appointed at the entity named in Paragraph 4 and have
obligations to disclose and assign certain invention rights to it. If that entity asserts an ownership
interest, VA will cooperate with it to manage the development of the invention as appropriate.
8.
If a Cooperative Research and Development Agreement (CRADA) exists between the VA and the
mentioned entity in paragraph 4, this agreement will be implemented in accordance with the provisions
of that agreement.
Signature
Date
Gerhard Schulteis, Ph.D., ACOS
Research and Development
Date
VA San Diego Healthcare System
Occupational Health - Without Compensation (WOC) Clearance
BY APPOINTMENT ONLY - CALL EXTENSION 3214 FOR APPOINTMENT
Section I: TYPE OR PRINT LEGIBLY
1. Name: ________________________________________________ Male
Female
(last, first, middle initial)
2. Full Social Security: _____-_____-_______
3. Date of Birth (mm/dd/yy)__________
4. Service/Section: ________________/_____________
5. Contact phone: _________________
6. Email Address: ________________@_________________
7. Agency affiliation: VA
UCSD
VMRF
Student/Trainee
Section II: Must be completed and signed by the Principal Investigator (PI)/Service POC:
(Prior to Occupational Health Appointment)
1.
2.
3.
4.
5.
6.
7.
8.
Anticipated Date of appointment for this WOC: ___________________________________
Anticipated Length of appointment: _____________________________________________
WOC Position Title: ____________________________________
Service/Section: ___________________/__________________________
Work location (be specific): _____________________
Name of Service administrator or designated contact:______________________________
Phone # and Extension of Service contact: _____________________________________
Will this individual be in contact with human or primate blood, tissue samples or have direct
patient contact other than verbal interaction? Yes
No
IF “yes” please describe below:
________________________________________________________________________________
________________________________________________________________________________
9. Name of PI/Service POC: _________________________________________________
10. Signature of PI/Service POC: _______________________________ Date: _________
Section III: Occupational Health Use Only
1. Quantiferon: Date blood drawn____________
2. Tuberculosis surveillance: Baseline
3. Initial: History of +ppd: Yes
Annual
No
Renewal
Date of CXR:____________
4. If ppd negative date of reading: __________
5. Date next TB test due: ________________
Final Clearance Date: ________________OH Signature: __________________________________
FINGERPRINT REQUEST FORM
Research WOC
INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service: Room 1508, Monday
–Friday, 7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.
Section I to be completed by the Employee
Name:
Date:
Other Names Used:
Position Title:
Social Security Number:
Service/Mail Code: RESEARCH
Phone:
Email:
Date of Birth:
City/State/Country of Birth:
Country of Citizenship:
Male
Anticipated Start Date (EOD):
Length of Appointment:
Applicant Category (check one): Paid
Resident Student
Contractor
Volunteer
Fee-Basis
Contract #:
MC (151)
Female
Work-Study
Research WOC: UCSD
/
IPA
VMRF
Extern
6 months
1 yr
2 yrs
Intern (non medical)
OTHER:
Contract Company:
Section II to be completed by Research POC or COTR
Service POC / COTR Sponsor: Robert Atienza
Send Fingerprint Results to: Robert Atienza
Phone: 858-552-8585 x1159
Mail Code : 151
Section III to be completed by Police Service
Date Completed:
Police Service Name:
Signature:
Section IIII to be completed by HUMAN RESOURCES
SAC Completed Date:
HR Name:
HR Signature:
**UPON COMPLETION OF THIS FORM POLICE SERVICE WILL ROUTE THIS FORM TO HUMAN RESOURCES**
FINGERPRINT VERIFICATION FORM
Research WOC
INSTRUCTIONS: Please fill out section I completely, then bring this form to Police Service with your Fingerprint Request form:
Room 1508, Monday –Friday, 7:00-3:15. Points of contact in the fingerprint office are Richard or Gina at 858-642-3531.
Section I to be completed by the Employee
Name:
Date:
Position Title:
Length of Appointment:
Social Security Number:
Service/Mail Code: RESEARCH
Phone:
Email:
Date of Birth:
City/State/Country of Birth:
Country of Citizenship:
Male
6 months
/
1 yr
2 yrs
MC (151)
Female
Section II to be completed by Research POC or COTR
Service POC / COTR Sponsor: Robert Atienza
Send Fingerprint Results to: Robert Atienza
Phone: 858-552-8585 x1159
Mail Code: 151
Section III to be completed by Police Service
Date Fingerprints Completed:
Police Service Name:
Signature:
**UPON COMPLETION OF THIS FORM RETURN TO RESEARCH ADMINISTRATION WITH YOUR WOC PACKET**
PIV Badge Request Form
Name: ___________________________
Date of Birth: __________________
Social Security Number: _____________
VA Computer Account: Y / N (va.gov only)
Place of Birth (city & state):_________________________
Research Job Title: ________________________________
E-Mail: _______________________________
Sex: M
Work Phone: _______________
F
Race: ________________
Height: _______________ (feet ‘inches)
Weight: _______________ (pounds)
Eyes: _________________
Hair: _________________
Research Admin Office Use Only
NACI Submitted: _____________
NACI Issues: ___________________________________________________
NACI Re-submitted: ___________
NACI Closed: ________________
PIV Badge Processed: __________
VA San Diego Healthcare System
WORK ASSOCIATED HAZARDS ASSESSMENT AND TRAINING CERTIFICATION
Please ask your Principal Investigator or Supervisor to assist you in completing this form
PI / Supervisor Name: Research Staff Name:
I am the PI
Position Title:
Paid By: VA
UCSD
VMRF
OTHER
Work Performed in: Building:
Room/s
After discussions with my supervisor it has been determined that I will (or will not) be involved in work with the
following hazards. I understand that I will receive the proper training prior to initiating this work. My supervisor
will documentation this training and it will be submitted to the research administrative office once completed. I also
understand that my supervisor will inform me of and train me in the proper handling of any new hazards as they are
introduced into the work area and complete an updated hazards assessment with me for submission.
1.
TRAINING: To be completed by VA and WOC Employees working in the VASDHS Research Department
The following components of the safety program are to be part of the annual training of all new and continuing employees
working in the VASDHS Research Department when first employed and periodically thereafter or whenever a new hazard
class is introduced into the workplace. Components A and B and C can be completed by self-study or discussion with the
supervisor. By signing and dating this sheet the employee and supervisor certify that those components CHECKED
were completed.
A. Review of Worksite (All Employees)
1. Fire extinguisher
2. Eye wash
3. Emergency power and lights
4. Spill kits
5. Types of hazards
6. Emergency exits
7. Material safety data sheet file location
8. Utilities and equipment
9. Signs and cautionary labels
10. Personal protective equipment
11. Fire alarm pull station
B. Review of Documents (All Employees)
1. Research Service Emergency Preparedness Procedures – Red Book (located at the doorway of each lab)
2. Service wide Safety Manual (relevant sections)
3. Laboratory Animal Hazards – Please see research staffing if you wish to participate in the VASDHS Laboratory Animal
Medical/Allergy Surveillance Program.
C. Specific Training (Please check all applicable according to duties and hazards classes selected below)
1. Handbook of Laboratory Safety
6. Medical Waste Disposal
2. Animal Handling
7. Sharps Disposal
3. Blood Borne Pathogens
8. Chemical Waste Disposal
4. Recombinant DNA
9. Hazardous Materials Disposal
5. Select Agents or Toxins
10. Waste Anesthetic Gas (WAG)
2.
HAZARDOUS MATERIALS:
Check any of the following BIOLOGICAL HAZARDS you will use or that are at your work location. N/A
HIV
HBV
TB
OTHER PATHOGENS/ETIOLOGIC AGENTS
NON-HUMAN CELLS, TISSUES OR FLUIDS
HUMAN CELLS, TISSUES OR FLUIDS
RECOMBINANT DNA
I am
/ am not
at occupational risk of exposure to blood borne pathogens.
If at risk, I have been offered and have elected
/ declined
/ received
the free hepatitis B vaccine.
Check any of the following CHEMICAL HAZARDS you will use or that are at your work location. N/A
HAZARDOUS CHEMICALS (OF ANY CLASS)
CYTOTOXICS
ETHYLENE OXIDE
COMPRESSED GASES
FORMALDEHYDE
CRYOGENIC LIQUIDS
MERCURY
BENZENE
WASTE ANESTHETIC GASES
VA San Diego Healthcare System
WORK ASSOCIATED HAZARDS ASSESSMENT AND TRAINING CERTIFICATION
Check any of the following RADIATION HAZARDS you will use or that are at your work location. N/A
LASERS
RADIOCHEMICALS
ULTRAVIOLET LIGHT
RADIO FREQUENCY / MICROWAVE SOURCES
RADIATION GENERATING EQUIPMENT
RADIOACTIVE MATERIALS
Check any of the following PHYSICAL HAZARDS you will be subject to at your work location. N/A
ANIMAL HANDLING
REPETITIVE MOTIONS
FLYING PARTICLES
FALLING/ROLLING OBJECTS
WORKING WITH SHARPS
3.
HEAVY LIFTING
EXCESSIVE NOISE
CONTACT WITH ELECTRICAL CONDUCTORS
EXTREME TEMPERATURES
PERSONAL PROTECTIVE EQUIPMENT:
I have been provided the following personal protective equipment for the checked hazards: N/A
EYE & FACE PROTECTION
FOOT PROTECTION
RESPIRATORY PROTECTION
HEARING PROTECTION
4.
HAND PROTECTION
HEAD PROTECTION
CERTIFICATIONS (Employees who checked ANY hazards in section 2 above must certify the statements below)
I have received training and have been determined to be competent on the equipment and hazardous material
classes with which I work.
I have successfully completed training on personal protective equipment required for my job. (Note this is required
once when PPE is issued and whenever new needs arise.)
When working with hazardous materials where there is a potential for spills or splashes I will, at a minimum, wear a knee
length lab coat, goggles, and closed toed shoes.
I have successfully completed training on the proper disposal procedures for the different categories of waste.
Employees with ONLY Administrative duties should certify the statement below.
My work does not involve the use of hazardous materials or chemicals and does not require the use of personal
protective equipment.
5.
COMPLIANCE STATEMENT
If the employee’s work location is VASDHS, I will comply with all Medical Center policies involving safety in the
workplace. If the work location is not at VASDHS, I will comply with all policies of the institution at which the employee
works. Records of training will be kept in the employee’s research personnel file.
PLEASE NOTE: PI’S DO NOT NEED A SUPERVISOR SIGNATURE, THEY MAY SIGN AS EMPLOYEE AND PI
_____________________________________________________________
Employee's Signature
______________________________
Date
_____________________________________________________________
Principal Investigator’s or Supervisor's Signature
______________________________
Date