Form VA 10-2850c Application for Associated Health Occupations

INSTRUCTIONS : APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS (VA Form 10-2850c)

A VA Form 10-2850c is a United States Department of Veteran Affairs form used for the application for employment in the associated health occupations.

The VA Form 10-2850c is available on the Veterans Affairs documentation website or can be supplied through a local Veterans Affairs office.

The first box is used to identify the position for which you are applying.

1. Select the position for which you are applying. If the position is not one of the named options, select “other” and write in the position in the box.

Boxes 2 through 12 are used for your personal identification information.

2. Fill in the appropriate boxes with your name, address, contact information, date of birth, social security number, citizenship, and past applications with the Veterans Affairs Department.

In Section I, box 13, identify whether you are currently or have ever been on active military duty.

3. If you have never been on active duty, leave these boxes blank.

Section II is to be used to identify all licenses or certifications that you hold.

4. In boxes 14 through 17, you must indicate all licenses that you currently hold or have held in the past. Do not leave out any certifications. If you need additional space for your list, attach them as an addendum at the end of the application.

Do not fill in information in Section III, this is for use only by the reviewing agency.

If you have any current or previous professional liability insurance, you must identify the carrier in Section IV and state whether your insurance has ever been canceled.

5. If you have had professional liability insurance canceled or denied, you must write a brief explanation on a separate sheet and attach it at the end of the VA Form 10-1850c.

In Sections V and VI, you must give a complete description of your education history and professional experience.

Sections VII and VIII are to be used for additional information and professional references.

6. Make sure to include all publications, papers and honors as they will help your application through the evaluation process.

Items 28 through 37 are general questions for employment with the federal government, for which you must supply yes or no answers.

Finally, certify the VA Form 10-2850c with your signature and submit it to the proper office for processing.

Form DA 2823 Sworn Statement

INSTRUCTIONS : SWORN STATEMENT (DA Form 2823)

A DA Form 2823 is a United States Army form for a sworn statement used for a variety of purposes. Sworn statements may be taken in documenting informal events or recording evidence for a formal investigation. The information taken on this form can be provided to non-military law enforcement agencies.

The DA Form 2823 is available on the United States Army documentation website or can be supplied through the Army chain of command.

The army personnel filing this form must first put the general information surrounding the investigation.

1. The location, date, time, and file number must be placed in boxes 1 through 4 in order to properly file the form and to ensure that it is properly documented under Army regulations.

Boxes 5 through 8 are used to identify the party that is giving the sworn statement.

2. The party giving the statement must provide on the document their name, social security number, their rank, and contact information.

Once this basic identifying information has been provided, the party giving the statement must write their name in box 9.

3. By putting their name in box 9, the party is swearing under oath that the statement is accurate and truthful. Failure to provide truthful information can lead to disciplinary action taken.

Box 9 should be filled out using the words of the declaring party.

4. Box 9 can be written by the swearing party or it can be written word for word by another party taking the statement.

5. It is highly important that the statement is neatly written so as to be understood by any other parties that may use the statement.

6. Should the statement not fit on the pages provided, the second page is available. If the provided pages do not support enough space, copies of the second page can be used as additional pages.

7. These additional pages must be identified and initialed by the party giving the statement.

Once the statement has been recorded and all signatures and initials placed in the proper boxes, the person making the statement must provide the affidavit on the final page of the DA Form 2823.

8. Witnesses must be present during the statement and must sign off on the affidavit.

9. Likewise, the party taking the statement must sign off on the DA Form 2823

Form VA 21-4142 Authorization and Consent to Release Information to the Department of Veterans Affairs

INSTRUCTIONS : AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE DEPARTMENT OF VETERANS AFFAIRS (VA) (VA Form 21-4142)

A VA Form 21-4142 is a United States Department of Veteran Affairs form used to authorize and provide consent for the release of medical information to the VA. This form must be on file before Veterans Affairs can review any medical or disability claims.

The VA Form 21-4142 is available on the Veterans Affairs documentation website or can be supplied through a local Veterans Affairs office.

The first Section is used for general identification information

1. Boxes 1, 2 and 4 are to be filled out with the veteran's name, file number, and social security number. These boxes must be filled in.

2. If a claimant other than the veteran is seeking benefits on behalf of the veteran, they must provide their name, relationship, and social security number in boxes 3, 5, and 6.

In Section II, you must identify all sources of medical information for which you are allowing Veterans Affairs to have.

3. You must include the name and addresses of all offices for which your medical or disability claim involves. You must also include the dates and conditions or illnesses for which you were treated.

4. In box 8, provide any additional comments about your consent that will be helpful for Veterans Affairs to seek your medical history and to view them.

Section III provides all of the important privacy information that the Department of Veterans Affairs will be held.

5. Read all of the information and check the authorization box in box 9c.

In box 10, the veteran, the claimant, or a legal representative must certify with their signature their consent of the Va Form 21-4142.

6. Provide your contact information including address and phone numbers. This is important as Veterans Affairs may need to contact you in regards to this form and to further obtain your consent for additional information they need for processing your claims.

In box 11, it is important that you have a witness sign and date the form. While this is not necessary for all medical records, Veterans Affairs may need a witness statement when seeking some of your records.

Once completed, your VA Form 21-4142 is ready for submission to Veterans Affairs. Keep a copy on record, as you may need to submit additional consent forms if you make additional claims.

Form DA 3161 Request for Issue or Turn-in

INSTRUCTIONS : REQUEST FOR ISSUE OR TURN-IN (DA Form 3161)

A DA Form 3161 is a United States Army form for a request for issue or turn in. The form is used for detailing supplies that are to be turned in or are being issued to a certain party.

The DA Form 3161 is available on the United States Army documentation website or can be supplied through the Army chain of command.

The party who is filing the DA Form 3161 must first identify whether the sheet is being used to report a turn in or an issue.

1. Check the appropriate box that corresponds to the use of this form.

Next you must supply all of the general information surrounding the request.

2. You must identify the request number and voucher number in boxes 1 and 2.

3. Boxes 3 through 9 will identify who the materials are being sent to, the date they are required, priority and authorizations, and all identifying information about the items to be issued or turned in.

Next, box 12 must be completed, which verifies all of the specific information about the items to be disbursed or turned in.

4. You must provide Item numbers, stock numbers, descriptions, quantities, codes, prices and cost for each individual item that is to be covered by your DA Form 3161.

5. All of the numbered quantities and costs must be added and totaled at the bottom of box 12.

Finally, the DA Form 3161 must be signed by the authorizing party, with all supply chain officers involved signing off on the issuance or turn in of the named supplies in the form.

6. A copy of the form should be kept for record keeping purposes, in order to assure that all items are accounted for and properly issued through the supply chain.

DD Form 577 Appointment Termination Record

INSTRUCTIONS : APPOINTMENT/TERMINATION RECORD (DD Form 577)

A DD Form 577 is a Department of Defense form is used for recording appointments and terminations of an officer in military or governmental functions. The form is used to identify and inform the officer of the appointment or the elimination of the appointment.

The DD Form 577 is available on the Department of Defense documentation website or can be supplied through the chain of command.

The first section of the DD Form 577 is to be filled out by the appointing authority.

1. The appointing authority must state the appointing official’s name and title in boxes 1 and 2.

2. In box 3, the appointing authority will identify itself with their Department of Defense component or organization name.

3. The appointing official will sign and date the form in boxes 4 and 5.

4. In section II, the appointing authority will identify the individual being appointed and provide their information, taken from Department of Defense records.

5. Boxes 6 through 11 must contain the name and contact information of the appointed officer. Their name, social security number, organization, title, address and telephone number should be filled in the appropriate boxes.

6. The appointing authority will indicate the date of appointment in box 12.

7. In boxes 13 and 14, the appointing authority will describe the position and the duties that will come with the appointment.

8. After sections I and II are filled out by the appointing authority, the DD Form 577 is to be given to the appointed official, who must acknowledge the appointment, signing boxes 16 and 17.

9. If or when the appointment terminates, the appointing authority can use the filed DD Form 577 and fill in the termination information in Section IV, revoking the appointment. Once revoked, the completed form must be provided to the appointed official to inform him or her of the termination of appointment.

Form DA 1594 Daily Staff Journal or Duty Officers Log

DAILY STAFF JOURNAL OR DUTY OFFICER’S LOG (DA Form 1594)

A DA Form 1594 is a United States Army form used to record the daily activities of a military member, recording information about daily training, operational reviews, and historical research.

The DA Form 1594 is available on the United States Army documentation website or can be supplied through the chain of command.

The first boxes that must be filled in are the upper right corner boxes indicating Page Number and Number of Pages.

1. Indicate Page Number 1 for the first sheet, but leave Number of Pages blank until the journal entry is completed.

Next, you will fill out your organization and location for which the journal entry is to be made.

In the boxes on the right, indicate the time period for which your journal entry is covering.

2. Journals are normally used to cover a 24 hour period, however you may use shorter or longer durations depending on the custom of your position and organization.

After the general information is supplied on the top section, you are ready to fill in the grid recording the information for your journal entry.

3. List the entries on the left side, providing a numerical value for each entry.

4. Indicate the time period for each specific entry.

The next box is to be used for indicating the event of the specific entry.

5. Specific events can be a wide range of topics, including incidents, messages, orders, or a host of other events that may have occurred throughout the day.

Next you will supply the action taken in response to the event that occurred in your entry.

6. Your entries should be brief so as to fit in the appropriate boxes.

7. Should your entries require additional space, you may use additional boxes or attach an addendum to the sheet to clarify the events.

Once the sheet is completed, each DA Form 1594 must be certified in the bottom boxes, with the name and rank of the officer and their signature.

8. Keep all DA Form 1594s in a safe place for recording and future reference.

Form DA 638 Recommendation for Award

INSTRUCTIONS : RECOMMENDATION FOR AWARD (DA Form 638)

A DA Form 638 is a United States Army form for the recommendation for an award. The form is used for most recommendations for awards, but not for heroism, valor, or wartime awards, which must use a separate process for recommendation.

The DA Form 638 is available on the United States Army documentation website or can be supplied through the Army chain of command.

The party who is filing the DA Form 638 must first identify in boxes 1 through 3 the military member who would receive the award, the recommending military member, their contact information, and the date.

Part I then requires specific information regarding the individual to receive the award.

1. In boxes 4 through 13, supply all information required, including name, contact information, branch, previous awards, awards recommended, and the reason for the award.

Next you must supply the specific information regarding the recommending individual.

2. Boxes 14 through 19 require the recommender’s general information and relationship to the awardee.

Part III of the DA Form 638 requires a detailed explanation of the achievements which have lead to this particular recommendation for an award.

3. Make sure to provide a detailed account in bullet form of any achievements which warrants the award. This will be used as an evaluation by the authorizing party to determine if the award should be given.

Part IV requires the documentation of all the approval through the chain of command that must be given in order for the recommendation of an award to be completed.

4. All certifying members through the chain of command must provide their information and sign off on the award to be given.

5. If additional personnel are required to approve the award, they can be listed on the addendum provided in the DA Form 638 as needed.

Once all members of the chain of command needed to approve the award have signed off on this form, the form is to be submitted to the appropriate HQ for processing.

6. The recommendation must face final approval which will also include the final order for the award or a denial with an explanation.

7. Details of the distribution of the award will be provided in the returned form.

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