S02_Attachment_14_-_New_Employee_Checklist.doc

36C24919R0003 – Marshall County CBOC

Attachment 14

Memphis VAMC New Employee Checklist (September 2018) Memphis VAMC Phone 901-523-8990, David Huhman Phone 901-577-7119 OIT Help Desk 855-673-4357 Option 2 then Option 3

Encryption Help Desk 1855-673-4357, Option 6, then Option 3

Credential POC Sheila Stout (x7345)

Credentialing staff will provide instructions. This takes time. Start early.

2. For Providers, (ie MD, NP, PA), to obtain prescribing authority through CPRS and for the emergency 10 day supplied locally.

3. For Providers, (ie MD, NP, PA) At least 2 providers at each CBOC to be Women’s Health Credentialed Initial – 20 hours Women’s Health (WH) courses. Subsequent – 10 hours WH courses every credentialing period

4. For Providers, (ie MD, NP, PA), review and sign the FPPE.

VHAMEM Clinic Profile

EMBED Word.Document.12 \s

6. For Clinical Staff, (RN, LPN, SW, X-ray Tech, etc), credentialing must be completed through HR.

POCs are David Morton, Frances Bishop, Malondria Hooker and Nia Scott. Send message to all 4.

Credentialing staff will provide instructions. This takes time. Be sure you start this process early.

7. For Social Workers, Scope of Practice must be completed.

POC is Rita Range, Chief, Social Work Service to make an appointment x7268

ICB POC is Randy Whiteside (x7875) Course # 5370 ICB

All the following steps apply to all new staff in addition to all of the above for certain Specialties:

10. Complete #10203 Privacy and HIPAA Training + #10176 VA Privacy & Info Security Awareness and Rules of Behavior in TMS. Annually TMS help desk line: 1-866-496-0463

Enroll as a contractor.

Do not enroll as a trainee.

Scan and e-mail certificates for the 2 courses to Donna Savoy.

Applicant self-enrolls in TMS using the following responses:

POC or Supervisor: enter David Huhman anywhere a POC is required

Location: enter Memphis TN (even though it’s a CBOC).

Name of contractor: enter the name of your company

Contract length: enter 5 years

Contract number: enter the number at the top left corner of your contract https://www.tms.va.gov/learning/user/selfEnrollmentUserSelection.do?emp_id=9

11. Initiate Background Investigation within 90 days of fingerprinting. If anything (especially SSN, BD, or e-mail address is not legible), process will not continue. Full legal name only. No nick names.

a. Complete all attached forms.

b. Fax or scan and e-mail Form 1 to your Contracting Officer for signature on line L

c. Contracting Officer signs and faxes or scans and e-mails it back to you.

d. Fax or scan and e-mail all forms to VHA Service Center (VSC) Personnel Security Office at Fax # (216) 447-8025 and notify your Contracting Officer (CO) and Donna Savoy (COTR).

e. If renewing PIV card, fill out all forms, plus OF 306, plus continuity form and get re-fingerprinted.

SAO Region: Central Investigation Level: Low COTR is David Huhman

12. Be Fingerprinted (SAC).

I recommend Memphis VA HR on the 2nd floor. No appointment necessary. They accept walk-ins. POC is Crystal Dockery (901-523-8991 x6609). Present completed Form 2 to the Memphis VA fingerprinting staff (or wherever fingerprints are done) which has the NEW SOI and SON. Submit to address on the form. If submitting hard copies, make sure the correct SOI (VA08) and SON (955C) numbers are written on the cards as well as the new employees name. Our SOI and SON numbers are different from the Memphis Medical Center numbers.

13. Complete e-QIP

a. Receive background check initiation (approval) from VSC

b. Receive/complete e-QIP instructions. Make sure staff are watching for this e-mail at the e-mail address they provided on their background forms. It may go to their spam folder. If they don’t complete e-QIP, they can’t get a computer access or a PIV card.

c. E-mail or Fax e-QIP completion to Donna Savoy fax 901-577-7434.

To complete e-QIP instructions, a Registration Code is required in order for the applicant to access their e-QIP account. An email will be sent to applicant with this Registration Code. If you do not receive the e-QIP e-mail contact the SIC Help Desk at (501) 257-4469/4490 to request the Registration Code and e-mail. Once the applicant receives their Registration Code they will be able to register, reset their personal password, access their account information and complete the e-QIP process. After the applicant receives their Registration Code please access the OPM e-QIP site at http://www.opm.gov/e-qip to complete the questionnaire.

14. Receive sign in codes from David Huhman after every step above has been completed.

15. Set up your signature codes.

On your desktop, Click the VA Shortcuts STAR button and select Vista – R3. Sign in with your Vista codes.

Type ^edit, and select Edit User Characteristics

Press enter until you reach: ELECTRONIC SIGNATURE CODE, enter just letters

At COMMAND: press e (to exit)

16. Get PIV Card within 120 days of fingerprinting.

a. After steps 9 thru 12 above, after you have computer access and after you are sponsored, applicant will receive the PIV Badge Courtesy Issue Request form by e-mail.

b. Applicant takes this form plus 2 forms of ID, with picture ID to VA Police on the ground floor of the VA, room # CEG7. Calling ahead to Bobby Bond or Melvin Mitchell (901-523-8991 x 2334 or 5596) to make an appt is best to make sure the PIV Card making equipment is functioning, but they will accept walk-ins.

c. OIT Help line if PIV card is not working at any time is (855) 673-4357 Option 5, Option 2

17. CPRS training: http://www.vehu.va.gov/cprs_training.cfm

_1549348559.pdf

Department of Veterans Affairs VHA Service Center Personnel Security

6100 Oak Tree Blvd #500 Independence, OH 44131

VSCSecurity@va.gov

VSC PERSONNEL SECURITY SERVICES OVERVIEW

The VHA Service Center Personnel Security Office offers a comprehensive service which ensures that contractor security requirements are met in accordance with OPM and federal regulations from initiation to completion.

Communication is maintained between the VSC, the contracting officer, the COR (COTR) and the contracting company point-of-contact at all times during the process.

This service includes the below:

Fingerprint submission and adjudication:

o This involves ensuring that contractors submit fingerprints for background screening and adjudication of fingerprint/background screening results. After the results are confirmed or adjudicated, the National Criminal History Check (NCHC) Form would be sent to all contacts via email.

Existing investigations:

o Verifying existing investigation information and collecting the required documents for reciprocity.

The required documentation would include the OF306 Form and Self-Certification Form. These documents would be provided upon confirmation of investigation through the OPM Portal.

New investigations:

o Upon receipt of the Contract Security Services Request, our office will obtain and submit all required documents to request an investigation through Little Rock Security Investigations Center (SIC) and monitor the progress through completion.

PIV Badges:

o Our office can also manage and sponsor the PIV badges as required, as soon as the investigations are released from Little Rock SIC and scheduled by OPM.

To begin the process, please follow the below guidelines:

1. Upon notification of contract award, make appointments for fingerprinting. Ensure contractors bring Form #2 Fingerprint Request Form and photo ID to their appointment. If fingerprints are to be taken manually, please refer to the mailing instructions on the bottom of Form #2.

2. Contracting officers, COR/COTRs complete and sign Form #1 in its entirety. All information is required. The packet will be rejected if this form is not complete.

3. Have employees complete all required documentation based on their risk level.

4. Submit complete packet to VSCSecurity@va.gov or fax: 216-447-8025. Incomplete packets will be rejected and returned. Complete packets will be assigned to a team member within 5-days. Subject line for the request submission email or fax cover sheet should be formatted as shown below.

a. New Request Packet - Contracted Company VA000-00000

b. Addition to Existing Request - Contracted Company VA000-00000

i. If there is a contact person in our office that is dealing with this specific task order, please put their name in the subject line as well.

c. Status Request – Contracted Company VA000-00000 submitted on 00/00/0000

5. Do not submit new requests and additions more than once as this will result in duplicate assignments and wasted time. If you have not received a response to your request within 5-7 business days, send a status request to the mailbox using the above format.

6. If there is a change in the contracted personnel (resignation, declined appointment, etc) immediately notify the team member handling your request. The cancellation must be submitted via email.

VSC Security Request Process

CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM 1A

Purpose: The Contract Security Services Request is submitted to VSC to initiate the contract security verification process. By submitting this form, our office will ensure that each individual listed have been fingerprinted, the fingerprints are adjudicated if necessary, background investigations are initiated or existing background investigations are current and PIV badges are managed and sponsored. This form should be completed and signed by the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.

A Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.

B COR (COTR) Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.

C Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).

D SAO Region: Please list the Service Area Office in which the contracting officer is associated with (East, West or Central).

E Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station.

Should the task order number change at fiscal year end, please indicate on any future requests by listing the old task order number in parenthesis next to the new task number.

F Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).

G Investigation Level: Please indicate the background security requirements as provided by the PDAT (Position Description Automated Tool). This would include background screening (SAC), low-level investigation (NACI), moderate-level investigation (MBI) and high-level investigation (BI). Please note that non-PIV badges (contract under 180-days) require at minimum a SAC, full PIV badges (over 180-days) require at minimum a NACI.

H Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

I Contractor Address: Please provide the contracting company address. This information is required for the Little Rock SIC investigation request.

J Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information.

This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

K Contractor POC Email: Please provide the email address for the above mentioned point-of-contact. This email will be included in the investigation request submitted to Little Rock SIC.

L Contracting Officer Signature: All requests must be signed by the contracting officer/specialist. This signature verifies that an official contract is in place prior to processing the applicants for investigation and badging.

M Station Number: Please indicate the facility station number where the work is being performed/facility to be billed.

N Network Access: Please indicate whether the individuals will be obtaining network access.

O Employee Name: Please provide the full legal name of the individuals working on this task order.

P SSN: Please provide complete social security numbers for all individuals listed.

Q Email Address: Please provide a valid email address for all individuals.

R DOB: Please provide date of birth for all individuals listed.

S Place of Birth: Please provide place of birth for all individuals listed, including city, state and country (if outside US). For foreign-born individuals, please provide proof of citizenship.

Revised Form April 2012

CONTRACT SECURITY SERVICES REQUEST FORM #1A

(Please see Instructional Form 1a for assistance in completing this form)

New Request Addition

CONTRACTOR INFORMATION

A VA Contracting Officer Name & Phone:

B COTR Name & Phone:

C Contract End Date (Including Options):

D SAO Region (East/West/Central):

E Purchase/Task Order Number:

F Contractor Position Description: M Station #:

G Investigation Level (SAC/Low/Moderate/High): N Network Access (Y/N):

H Contract Company Name (Subcontractor):

I Contract Company Address:

J Contractor POC Name & Phone:

K Contractor POC Email:

L Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

O P Q R S

*Please use Supplemental Form 1b for additional individuals

CONTRACTOR EMPLOYEE INFORMATION

Employee Name

(Full Legal Name) SSN Email Address D.O.B.

Place of Birth (City, State/Country)

CONTRACTOR / EMPLOYEE FINGERPRINT REQUEST INSTRUCTIONAL FORM 2A

Purpose: The Contractor/Employee Fingerprint Request is to assist individuals in obtaining fingerprinting services from VA Facilities nationwide, on behalf of the VSC. This form is required by Little Rock SIC before a request for investigation can be submitted.

A Full Legal Name: Please provide full legal name of individual requiring fingerprints.

B SSN Last Four: Please provide the last four of the individual’s social security number.

C Contractor (Yes/No): Please indicate whether the individual is a contractor. Contracted employees are considered contractors.

D VAMC Location: Please provide the name and location of the VA Facility where the fingerprints were submitted.

E Station Number: Please provide the station number of the VA Facility where the fingerprints were submitted.

F Date Fingerprinted: Please provide the date that the fingerprints were submitted at the VA Facility.

G Method of Fingerprinting: Please indicate whether the fingerprints were submitted electronically or if manual fingerprints were submitted with ink and fingerprint card.

H Date Card Mail to OPM: If fingerprints were submitted manually, please provide the date the card was mailed to

IMPORTANT NOTE:

If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below. Delivery confirmation is recommended.

OPM Rapid Response Team / OPM-FIPC 1137 Branchton Rd Boyers, PA 16020

*All fields on the fingerprint card MUST be completed or the card will be destroyed.

SON: VA08 SOI: 955C

IPAC/OPAC: 3600.1200

APPLICANT SIGNATURE

APPLICANT COMPLETE ADDRESS

DATE SIGNATURE OF OFFICIAL

EMPLOYER COMPLETE ADDRESS

CITIZENSHIP

SOC SEC #

LAST NAME FIRST NAME MIDDLE

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

A Full Legal Name (First Middle Last):

B SSN Last Four:

C Contractor (Yes/No):

After fingerprints are captured, return this completed form to your CO/COR for submission to VSC

*If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below, with this form. All fields on the fingerprint card MUST be completed.

Please refer to Instructional Form #2a for an example of a completed fingerprint card. OPM will destroy all cards with incomplete fields. Delivery confirmation is recommended.

FACILITY INFORMATION

D VAMC Name & Location:

E Station Number:

F Date Fingerprinted:

G Method of Fingerprinting: Electronically / Manually

H Date Card Mailed to OPM*:

PIV SPONSORSHIP INSTRUCTIONAL FORM 3A

Purpose: The PIV Sponsorship Form is used to complete the PIV badge application through the nationwide portal. All information is required to process a PIV badge. All fields are mandatory except the VA.GOV email address.

A Full Legal Name: Please provide full legal name of individual as shown on driver’s license or photo ID.

B Date of Birth: Please provide the date of birth of the individual.

C Social Security Number: Please provide the social security number of the individual.

D Citizenship: Please provide the citizenship of the individual. All foreign-born individuals will be required to submit proof of citizenship.

E Assigned Duty Station: Please provide the name of the individual’s assigned duty station.

F Address of Assigned Duty Station: Please provide the complete address of the assigned duty station.

G VA.GOV Email Address: Please provide the va.gov email address of the individual. If the individual has not had the email address established, or will not be obtaining an email address, please indicate pending or not applicable.

H Gender: Please provide gender of individual.

I Race: Please provide race of individual.

J Height: Please provide height of individual.

K Weight: Please provide weight of individual.

L Eye Color: Please provide eye color of individual.

M Hair Color: Please provide hair color of individual.

N Place of Birth: Please provide city, state and country of individual’s place of birth.

All foreign-born individuals will be required to provide proof of citizenship.

O Position Title: Please provide position title of individual.

P Contractor Company Name: Please provide the contracting company that the individual will be working under. If the individual is a VA employee, please indicate not applicable.

Q Contracting Company Address: Please provide the contracting company address. If the individual is a VA employee, please indicate not applicable.

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship: (US Citizen, Naturalized, Non-Citizen)

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

CONTRACT SECURITY VERIFICATION REQUEST SUPPLEMENTAL FORM #1B

(This form is used only when extra space is needed for large rosters.)

(Please reference Instructional Form #1b for assistance in completing this form)

A Contracting Officer Name & Phone:

C Task Order Number:

D Contract Company Name (Subcontractor):

E Contractor POC Name & Phone:

F G H I J

SECURITY VERIFICATION CONTINUATION

INSTRUCTIONAL FORM 1B

A Contracting Officer Name & Phone: Please list the post-award contracting officer or specialist handling this task order and phone number.

B COTR Name & Phone: Please list the Contracting Officer Technical Representative and phone number. The COTR is the liaison between the contracting officer and contracted company.

C Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station. Should the task order number change at fiscal year end, please indicate this on any future request worksheets by listing the old task order number in parenthesis.

D Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

E Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information. This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

F Employee Name: Please provide the full legal name of the individuals working on this task order. If the individual is working on multiple task orders, please list them again as our database tracks contract statistics.

G SSN: Please provide complete social security numbers for all individuals listed.

H Email Address: Please provide a valid email address for all individuals. This email address will be provided for EQIP communication.

I DOB: Please provide date of birth for all individuals listed.

J Place of Birth: Please provide place of birth for all individuals listed, including city, state and country. For foreign-born individuals, please provide proof of citizenship.

CO:

CheckBox2: Off

CheckBox6: Off

COR:

CONTRACT END:

SAO:

PO/TO:

POSITION:

STATION:

Y/N:

RISK:

COMPANY:

CO ADDRESS:

CO POC:

CO POC EMAIL:

CO SIGNATURE:

E1:

E2:

E3:

E4:

E5:

E6:

E7:

S1:

S2:

S3:

S4:

S5:

S6:

S7:

EM1:

d1:

d2:

d3:

EM2:

EM3:

EM4:

EM5:

EM6:

EM7:

d4:

d5:

d6:

d7:

b1:

B2:

b3:

b5:

b4:

b6:

b7:

f2a:

f2b:

f2c:

f2d:

f2e:

f2f:

f2g:

3a:

3b:

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3d:

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3f:

3g:

3h:

3i:

3j:

3k:

3l:

3m:

3n:

3o:

3p:

3q:

3r:

3s:

1b1:

1b2:

1b3:

1b4:

1b5:

1:

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33:

44:

55:

66:

77:

88:

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111:

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555:

666:

777:

888:

999:

21:

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_1566108275.doc Memphis VAMC New Employee Checklist (March 2017)

Memphis VAMC Phone 901-523-8990, Donna Savoy Phone 901-577-7545

OIT Help Desk 855-673-4357 Option 2 then Option 3

Encryption Help Desk 1855-673-4357, Option 6, then Option 3

Action Needed

Point of Contact

Paperwork

1. For Providers, (ie MD, NP, PA), credentialing must be completed

CV to Donna Savoy for concurrence prior to submitting credentialing.

Credential POC Sheila Stout (x7345)

Credentialing staff will provide instructions. This takes time. Start early.

2. For Providers, (ie MD, NP, PA), to obtain prescribing authority through CPRS and for the emergency 10 day supplied locally.

Provide which CBOC, new employee name, and their DEA and NPI to Timmye Edwards, PharmD (x5814)

To add a local pharmacy to the Heritage Health program, send pharmacy information to Edwards as well

3. For Providers, (ie MD, NP, PA)

At least 2 providers at each CBOC to be Women’s Health Credentialed

Initial – 20 hours WH courses

Subsequent – 10 hours WH courses every credentialing period

4. For Providers, (ie MD, NP, PA), review and sign the FPPE.

POC is Gail Berntson, MD (x5539)

Recurring requirement

5. For Providers, (MD, NP, PA, SW), complete Clinical Profile form to indicate Provider schedule to see patients.

POC is Charles Miller (x5674) or

Gayle Clemons (ext. 5138)

Submit form to:

VHAMEMCPro@med.va.gov.

EMBED Word.Document.12 \s

6. For Clinical Staff, (RN, LPN, SW, X-ray Tech, etc), credentialing must be completed through HR.

POCs are David Morton, Frances Bishop, Malondria Hooker and Nia Scott. Send message to all 4.

Credentialing staff will provide instructions. This takes time. Be sure you start this process early.

7. For Social Workers, Scope of Practice must be completed.

POC is Cecilia Graham, to make an appointment x7268

8. For Schedulers, take scheduling training. See attachment for instructions.

POC is Detrick Bryant (x7864).

ICB POC is Randy Whiteside (x7875)

Course # 5370 ICB

All the following steps apply to all new staff in addition to all of the above for certain Specialties:

9. Provide information to request computer access.

E-mail (encrypt) or Fax the applicant’s full name, SSN, BD and Job Title to Donna Savoy fax 901-577-7434.

10. Complete #10203 Privacy and HIPAA Training + #10176 VA Privacy & Info Security Awareness and Rules of Behavior in TMS. Annually

TMS help desk line: 1-866-496-0463

Enroll as a contractor.

Do not enroll as a trainee.

Scan and e-mail certificates for the 2 courses to Donna Savoy.

Applicant self-enrolls in TMS using the following responses:

POC or Supervisor: enter Donna Savoy anywhere a POC is required

Location: enter Memphis TN (even though it’s a CBOC).

Name of contractor: enter the name of your company

Contract length: enter 5 years

Contract number: enter the number at the top left corner of your contract https://www.tms.va.gov/learning/user/selfEnrollmentUserSelection.do?emp_id=9

11. Initiate Background Investigation within 90 days of fingerprinting. If anything (especially SSN, BD, or e-mail address is not legible), process will not continue. Full legal name only. No nick names.

a. Complete all attached forms.

b. Fax or scan and e-mail Form 1 to your Contracting Officer for signature on line L

c. Contracting Officer signs and faxes or scans and e-mails it back to you.

d. Fax or scan and e-mail all forms to VHA Service Center (VSC) Personnel Security Office at Fax # (216) 447-8025 and notify your Contracting Officer (CO) and Donna Savoy (COTR).

e. If renewing PIV card, fill out all forms, plus OF 306, plus continuity form and get refingerprinted.

SAO Region: Central Investigation Level: Low COTR is Donna Savoy

12. Be Fingerprinted (SAC).

I recommend Memphis VA HR on the 2nd floor. No appointment necessary. They accept walk-ins. POC is Crystal Dockery (901-523-8991 x6609). Present completed Form 2 to the Memphis VA fingerprinting staff (or wherever fingerprints are done) which has the NEW SOI and SON. Submit to address on the form. If submitting hard copies, make sure the correct SOI (VA08) and SON (955C) numbers are written on the cards as well as the new employees name. Our SOI and SON numbers are different from the Memphis Medical Center numbers.

13. Complete e-QIP

a. Receive background check initiation (approval) from VSC

b. Receive/complete e-QIP instructions. Make sure staff are watching for this e-mail at the e-mail address they provided on their background forms. It may go to their spam folder. If they don’t complete e-QIP, they can’t get a computer access or a PIV card.

c. E-mail or Fax e-QIP completion to Donna Savoy fax 901-577-7434.

To complete e-QIP instructions, a Registration Code is required in order for the applicant to access their e-QIP account. An email will be sent to applicant with this Registration Code. If you do not receive the e-QIP e-mail contact the SIC Help Desk at (501) 257-4469/4490 to request the Registration Code and e-mail. Once the applicant receives their Registration Code they will be able to register, reset their personal password, access their account information and complete the e-QIP process. After the applicant receives their Registration Code please access the OPM e-QIP site at http://www.opm.gov/e-qip to complete the questionnaire.

14. Receive sign in codes from Donna Savoy after every step above has been completed.

15. Set up your signature codes.

On your desktop, Click VistA3-SSH. Sign in with your Vista codes.

Type ^edit, and select Edit User Characteristics

Press enter until you reach: ELECTRONIC SIGNATURE CODE, enter just letters

At COMMAND: press e (to exit)

16. Get PIV Card within 120 days of fingerprinting.

a. After steps 9 thru 12 above, after you have computer access and after you are sponsored, applicant will receive the PIV Badge Courtesy Issue Request form by e-mail.

b. Applicant takes this form plus 2 forms of ID, with picture ID to VA Police on the ground floor of the VA, room # CEG7. Calling ahead to Bobby Bond or Melvin Mitchell (901-523-8991 x 2334 or 5596) to make an appt is best to make sure the PIV Card making equipment is functioning, but they will accept walk-ins.

c. OIT Help line if PIV card is not working at any time is (855) 673-4357 Option 5, Option 2

17. CPRS training: http://www.vehu.va.gov/cprs_training.cfm

_1525155405.pdf

NEW OR REVISED CLINIC REQUEST FORM

CLINIC NAME: MEM DERM A ABBREVIATION: DERM SERVICE: PSYCHIATRY

Note: Clinic Name should be Site/Location, Service/Dept and Provider Name or use numbers or alpha letters. Try to use abbreviations as the first 3 or 4 letters of the provider name or if used by more than one provider, then the first 3 or 4 letters of a clinic name easily recognizable to all.

CHECK DAYS HELD AND ENTER APPOINTMENT TIME(S) FOR EACH DAY BELOW:

Mon Tue Wed Thu Fri Sat Sun 9:00 9:00 9:00 1:00 9:00 11:00 11:00 11:00 3:00 11:00 1:00 1:00

START DATE: 3-11-16 PRIMARY PROVIDER: John Smith TELEPHONE: 901-523-8990 EXT: 5062

REQUIRE X-RAY FILMS (Y/N): N PHYSICAL LOCATION (BLDG/ROOM): 1ST FL/ RM 203

NUMBER OF OVERBOOKS ALLOWED PER DAY: 5

LENGTH OF APPOINTMENT: 60 minutes

VARIABLE LENGTH: YES OR NO (**gives the option to increase**)

NUMBER OF PATIENTS PER APPOINTMENT SLOT: 4

PRIVILEGED USERS WHO NEED ACCESS TO THIS CLINIC:

Charles Miller, Gayle Clemons

WILL ENCOUNTER FORMS NEED TO BE SETUP/CREATED? Y/N: Y

DO PATIENTS NEED TO BE CALLED BY THE AUTOMATED REMINDER SYSTEM? Y/N Y

WILL LABS BE ORDERED FROM THIS LOCATION? Y/N N

SPECIAL INSTRUCTIONS FOR SCHEDULERS: Overbooks to be approved by designee

STOP CODE 539 CREDIT STOP 510

The following information will be used by the DSS Department only.

MAP TO DSS DEPARTMENT NAME:

Relative Value Unit’s (RVU): VL 1 (Techs) VL 2 (RNs) VL 4 (MDs) VL 5 (Contract Labor)

REQUESTING PROVIDER SIGNATURE (if appropriate)

APPROVING SERVICE CHIEF/CLINIC MANAGER SIGNATURE

CLINIC SETUP COMPLETED BY DATE

ONLY enter START

TIMES. NO BREAKS OR

WINDOWS OF TIME

**PLEASE** provide main number and extension on every request

A SHORTCUT command

TO TYPE IN VISTA TO

BRING UP CLINIC.

Always provide # PATIENTS for every appt time.

**It is extremely important to note whether the form is for a NEW or REVISED clinic. Delete one or the other**

**Must have a

START DATE**

CHOICES: MEDICINE,

SURGERY, PSYCHIATRY,

REHAB MEDICINE,

NEUROLOGY, NONE

Stop Codes & Credit Stop

Needed

**Follow local naming conventions**

Floor and room number

_1545026965.pdf

Self Certification of Continuous Service

I hereby certify that my break in service following my last investigation is indicated by the block checked below.

(Check one)

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than 2 years. (You are required to submit the OF 306, Declaration for

Federal Employment, with this form.)

My break in service is greater than 2 years or; I have never worked for the federal government.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

DEPARTMENT OF VETERANS AFFAIRS

I have NOT had a break in service: Off

My break in service was less than 60 days: Off

My break in service was greater than 60 days but less than 2: Off

My break in service is greater than 2 years or I have never worked: Off

Print Name:

Social Security Number:

Date:

Current Investigation in PIPS:

Date_2:

Risk level of current position:

Verified by:

_1563087172.doc

Scheduling Training through TMS:

1. The modules on Scheduling are located on TMS.

2. This training has been mandated for all schedulers and their supervisors to ensure staff have the necessary competencies to manage scheduling.

3. To gain access to TMS, have the employee self-enroll.

4. Once you log onto TMS, in the search box, type scheduling training and each will appear. After taking each test, employees should print a certificate and fax it to Marion Herring and Detrick Bryant, 136D, Business Office Training Specialist at 901-577-7283 or save it and e-mail it to Marion Herring and Detrick Bryant.

5. The training classes for TMS are:

a. VA 7532 Scheduling Training – Recall Reminder

b. VA 7534 Scheduling Training – Business Rules

c. VA 7535 Scheduling Training – Make Appointments

d. VA 7533 Scheduling Training – Soft Skills

e. VA 29961 Scheduling Directive 1230 - Read the Directive

f. VA 29756 My VA Access Mental Health Initiative

DWHP Courses

All 1 hour courses unless otherwise marked.

1. 11906 Women's Health Emergency Care Series - Vaginal Bleeding 3 hours

1. 12647 Women's Health Care: Clinical Breast Exam

1. 14356 Women's Health Primary Care Series: Breast and Pelvic Examination Course, Independent Study 2.5

1. 15165 Women's Health Emergency Care Series - Acute Pelvic Pain 1.5 hours

1. 15235 Women's Health Primary Care Series: Breast and Pelvic Examination Instructor Course

1. 15676 Caring for Women Veterans - For All Employees

1. 16769 Women's Health Emergency Care Series - Pelvic Inflammatory Disease

1. 15770 Women's Health Emergency Care Series - Sexual Assault

1. 21629 An Introduction to Transgender Veteran Health Care

1. 24767 Geriatric Evaluation and Management Series (GEMS): Osteoporosis (recording)

1. 26598 Women's Health Mini Residency Primary Care Nursing: Pelvic Exam and Cervical Cancer

1. 29806 Women’s Health Mini-Residency Primary Care Providers: Abnormal Uterine Bleeding

1. 29807 Women's Health Mini-Residency Primary Care Providers: Breast Issues

1. 29808 Women's Health Mini-Residency Primary Care Providers: Chronic Pelvic Pain

1. 29809 Women's Health Mini-Residency Primary Care Providers: Contraception

1. 29810 Women's Health Mini-Residency Primary Care Providers: Gynecologic Emergencies

1. 29811 Women's Health Mini-Residency Primary Care Providers: Innovation Organizational Change 0.5 hrs

1. 29812 Women's Health Mini-Residency Primary Care Providers: Interpersonal Violence

1. 29813 Women's Health Mini-Residency Primary Care Providers: Menopause

1. 29814 Women's Health Mini-Residency Primary Care Providers: Pharmacy

1. 29815 Women's Health Mini-Residency Primary Care Providers: Vaginitis & Cervicitis

1. 31115 Do Ask, Do Tell: Assessing Sexual Health of LGBT Veterans (and Everyone Else) 1.5 hours

1. 9963 Military Sexual Trauma (MST) Training for Medical Providers

_1549348559.pdf

VSC PERSONNEL SECURITY SERVICES OVERVIEW

The VHA Service Center Personnel Security Office offers a comprehensive service which ensures that contractor security requirements are met in accordance with OPM and federal regulations from initiation to completion.

Communication is maintained between the VSC, the contracting officer, the COR (COTR) and the contracting company point-of-contact at all times during the process.

This service includes the below:

Fingerprint submission and adjudication:

o This involves ensuring that contractors submit fingerprints for background screening and adjudication of fingerprint/background screening results. After the results are confirmed or adjudicated, the National Criminal History Check (NCHC) Form would be sent to all contacts via email.

Existing investigations:

o Verifying existing investigation information and collecting the required documents for reciprocity.

The required documentation would include the OF306 Form and Self-Certification Form. These documents would be provided upon confirmation of investigation through the OPM Portal.

New investigations:

o Upon receipt of the Contract Security Services Request, our office will obtain and submit all required documents to request an investigation through Little Rock Security Investigations Center (SIC) and monitor the progress through completion.

PIV Badges:

o Our office can also manage and sponsor the PIV badges as required, as soon as the investigations are released from Little Rock SIC and scheduled by OPM.

To begin the process, please follow the below guidelines:

1. Upon notification of contract award, make appointments for fingerprinting. Ensure contractors bring Form #2 Fingerprint Request Form and photo ID to their appointment. If fingerprints are to be taken manually, please refer to the mailing instructions on the bottom of Form #2.

2. Contracting officers, COR/COTRs complete and sign Form #1 in its entirety. All information is required. The packet will be rejected if this form is not complete.

3. Have employees complete all required documentation based on their risk level.

4. Submit complete packet to VSCSecurity@va.gov or fax: 216-447-8025. Incomplete packets will be rejected and returned. Complete packets will be assigned to a team member within 5-days. Subject line for the request submission email or fax cover sheet should be formatted as shown below.

a. New Request Packet - Contracted Company VA000-00000

b. Addition to Existing Request - Contracted Company VA000-00000

i. If there is a contact person in our office that is dealing with this specific task order, please put their name in the subject line as well.

c. Status Request – Contracted Company VA000-00000 submitted on 00/00/0000

5. Do not submit new requests and additions more than once as this will result in duplicate assignments and wasted time. If you have not received a response to your request within 5-7 business days, send a status request to the mailbox using the above format.

6. If there is a change in the contracted personnel (resignation, declined appointment, etc) immediately notify the team member handling your request. The cancellation must be submitted via email.

VSC Security Request Process

CONTRACT SECURITY SERVICES REQUEST - INSTRUCTIONAL FORM 1A

Purpose: The Contract Security Services Request is submitted to VSC to initiate the contract security verification process. By submitting this form, our office will ensure that each individual listed have been fingerprinted, the fingerprints are adjudicated if necessary, background investigations are initiated or existing background investigations are current and PIV badges are managed and sponsored. This form should be completed and signed by the contracting officer. Please refer to the instructions below when completing the Contract Security Services Request Form #1.

A Contracting Officer & Phone: Please provide the post-award contracting officer handling this contract and their phone number.

B COR (COTR) Name & Phone: Please list the Contracting Officer Representative (previously the Contracting Officer Technical Representative) and phone number. The COR is the liaison between the contracting officer and contracted company.

C Contract End Date: Please list the date in which the contract ends including all options to extend (for PIV badge expiration).

D SAO Region: Please list the Service Area Office in which the contracting officer is associated with (East, West or Central).

E Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station.

Should the task order number change at fiscal year end, please indicate on any future requests by listing the old task order number in parenthesis next to the new task number.

F Contractor Position Description: Please provide a position title for all individuals (ex: physician, consultant, electrician).

G Investigation Level: Please indicate the background security requirements as provided by the PDAT (Position Description Automated Tool). This would include background screening (SAC), low-level investigation (NACI), moderate-level investigation (MBI) and high-level investigation (BI). Please note that non-PIV badges (contract under 180-days) require at minimum a SAC, full PIV badges (over 180-days) require at minimum a NACI.

H Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

I Contractor Address: Please provide the contracting company address. This information is required for the Little Rock SIC investigation request.

J Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information.

This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

K Contractor POC Email: Please provide the email address for the above mentioned point-of-contact. This email will be included in the investigation request submitted to Little Rock SIC.

L Contracting Officer Signature: All requests must be signed by the contracting officer/specialist. This signature verifies that an official contract is in place prior to processing the applicants for investigation and badging.

M Station Number: Please indicate the facility station number where the work is being performed/facility to be billed.

N Network Access: Please indicate whether the individuals will be obtaining network access.

O Employee Name: Please provide the full legal name of the individuals working on this task order.

P SSN: Please provide complete social security numbers for all individuals listed.

Q Email Address: Please provide a valid email address for all individuals.

R DOB: Please provide date of birth for all individuals listed.

S Place of Birth: Please provide place of birth for all individuals listed, including city, state and country (if outside US). For foreign-born individuals, please provide proof of citizenship.

CONTRACT SECURITY SERVICES REQUEST FORM #1A

(Please see Instructional Form 1a for assistance in completing this form)

New Request Addition

CONTRACTOR INFORMATION

A VA Contracting Officer Name & Phone:

C Contract End Date (Including Options):

D SAO Region (East/West/Central):

E Purchase/Task Order Number:

F Contractor Position Description: M Station #:

G Investigation Level (SAC/Low/Moderate/High): N Network Access (Y/N):

H Contract Company Name (Subcontractor):

I Contract Company Address:

J Contractor POC Name & Phone:

K Contractor POC Email:

L Contracting Officer Signature:

***This signature verifies that an official contract is in place prior to processing the applicants for badging***

O P Q R S

*Please use Supplemental Form 1b for additional individuals

CONTRACTOR EMPLOYEE INFORMATION

CONTRACTOR / EMPLOYEE FINGERPRINT REQUEST INSTRUCTIONAL FORM 2A

Purpose: The Contractor/Employee Fingerprint Request is to assist individuals in obtaining fingerprinting services from VA Facilities nationwide, on behalf of the VSC. This form is required by Little Rock SIC before a request for investigation can be submitted.

A Full Legal Name: Please provide full legal name of individual requiring fingerprints.

B SSN Last Four: Please provide the last four of the individual’s social security number.

C Contractor (Yes/No): Please indicate whether the individual is a contractor. Contracted employees are considered contractors.

D VAMC Location: Please provide the name and location of the VA Facility where the fingerprints were submitted.

E Station Number: Please provide the station number of the VA Facility where the fingerprints were submitted.

F Date Fingerprinted: Please provide the date that the fingerprints were submitted at the VA Facility.

G Method of Fingerprinting: Please indicate whether the fingerprints were submitted electronically or if manual fingerprints were submitted with ink and fingerprint card.

H Date Card Mail to OPM: If fingerprints were submitted manually, please provide the date the card was mailed to

IMPORTANT NOTE:

If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below. Delivery confirmation is recommended.

*All fields on the fingerprint card MUST be completed or the card will be destroyed.

APPLICANT SIGNATURE

APPLICANT COMPLETE ADDRESS

DATE SIGNATURE OF OFFICIAL

EMPLOYER COMPLETE ADDRESS

CITIZENSHIP

SOC SEC #

LAST NAME FIRST NAME MIDDLE

CONTRACTOR/EMPLOYEE FINGERPRINTING REQUEST FORM #2

SON: 955C / SOI: VA08 IPAC/OPAC: 3600.1200

(Please see Instructional Form #2a for assistance in completing this form)

** This form must be taken to the fingerprinting appointment **

EMPLOYEE INFORMATION (PLEASE PRINT)

B SSN Last Four:

C Contractor (Yes/No):

After fingerprints are captured, return this completed form to your CO/COR for submission to VSC

*If fingerprints are manually taken, please ensure the FD-258 Fingerprint Card is used and that it is mailed directly to OPM at the address below, with this form. All fields on the fingerprint card MUST be completed.

Please refer to Instructional Form #2a for an example of a completed fingerprint card. OPM will destroy all cards with incomplete fields. Delivery confirmation is recommended.

FACILITY INFORMATION

D VAMC Name & Location:

E Station Number:

F Date Fingerprinted:

G Method of Fingerprinting: Electronically / Manually

H Date Card Mailed to OPM*:

PIV SPONSORSHIP INSTRUCTIONAL FORM 3A

Purpose: The PIV Sponsorship Form is used to complete the PIV badge application through the nationwide portal. All information is required to process a PIV badge. All fields are mandatory except the VA.GOV email address.

A Full Legal Name: Please provide full legal name of individual as shown on driver’s license or photo ID.

B Date of Birth: Please provide the date of birth of the individual.

C Social Security Number: Please provide the social security number of the individual.

D Citizenship: Please provide the citizenship of the individual. All foreign-born individuals will be required to submit proof of citizenship.

E Assigned Duty Station: Please provide the name of the individual’s assigned duty station.

F Address of Assigned Duty Station: Please provide the complete address of the assigned duty station.

G VA.GOV Email Address: Please provide the va.gov email address of the individual. If the individual has not had the email address established, or will not be obtaining an email address, please indicate pending or not applicable.

H Gender: Please provide gender of individual.

I Race: Please provide race of individual.

J Height: Please provide height of individual.

K Weight: Please provide weight of individual.

L Eye Color: Please provide eye color of individual.

M Hair Color: Please provide hair color of individual.

N Place of Birth: Please provide city, state and country of individual’s place of birth.

All foreign-born individuals will be required to provide proof of citizenship.

O Position Title: Please provide position title of individual.

P Contractor Company Name: Please provide the contracting company that the individual will be working under. If the individual is a VA employee, please indicate not applicable.

Q Contracting Company Address: Please provide the contracting company address. If the individual is a VA employee, please indicate not applicable.

VHA SERVICE CENTER PIV SPONSORSHIP FORM #3

(Please see Instruction Form #3a for assistance in completing this form)

CONTRACTOR / EMPLOYEE INFORMATION

* All fields are mandatory except va.gov email *

B Date of Birth (MM/DD/YYYY):

C Social Security Number:

D Citizenship: (US Citizen, Naturalized, Non-Citizen)

E Assigned Duty Station:

F Address of Assigned Duty Station:

G VA.GOV Email Address:

H Gender:

I Race:

J Height:

K Weight:

L Eye Color:

M Hair Color:

N Place of Birth (City, State, Country):

O Position Title:

P Contractor Company Name:

Q Company Address:

CONTRACT SECURITY VERIFICATION REQUEST SUPPLEMENTAL FORM #1B

(Please reference Instructional Form #1b for assistance in completing this form)

A Contracting Officer Name & Phone:

C Task Order Number:

D Contract Company Name (Subcontractor):

E Contractor POC Name & Phone:

F G H I J

SECURITY VERIFICATION CONTINUATION

INSTRUCTIONAL FORM 1B

A Contracting Officer Name & Phone: Please list the post-award contracting officer or specialist handling this task order and phone number.

B COTR Name & Phone: Please list the Contracting Officer Technical Representative and phone number. The COTR is the liaison between the contracting officer and contracted company.

C Task Order Number: Please list the task order number (VA000-C00000). Our database is based on tracking contracts by station. Should the task order number change at fiscal year end, please indicate this on any future request worksheets by listing the old task order number in parenthesis.

D Contract Company Name: Please provide the name of the contracting company that will be providing the work under the task order. Please provide subcontractors in parenthesis.

E Contractor POC Name & Phone: Please provide the main point-of-contact for the contracting company and contact information. This person may be contacted to provide additional information or documents in the process. All communication with this individual will include the contracting officer and COTR.

F Employee Name: Please provide the full legal name of the individuals working on this task order. If the individual is working on multiple task orders, please list them again as our database tracks contract statistics.

G SSN: Please provide complete social security numbers for all individuals listed.

H Email Address: Please provide a valid email address for all individuals. This email address will be provided for EQIP communication.

I DOB: Please provide date of birth for all individuals listed.

J Place of Birth: Please provide place of birth for all individuals listed, including city, state and country. For foreign-born individuals, please provide proof of citizenship.

CO:

CheckBox2: Off

CheckBox6: Off

COR:

CONTRACT END:

SAO:

PO/TO:

POSITION:

STATION:

Y/N:

RISK:

COMPANY:

CO ADDRESS:

CO POC:

CO POC EMAIL:

CO SIGNATURE:

E1:

E2:

E3:

E4:

E5:

E6:

E7:

S1:

S2:

S3:

S4:

S5:

S6:

S7:

EM1:

d1:

d2:

d3:

EM2:

EM3:

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EM6:

EM7:

d4:

d5:

d6:

d7:

b1:

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b3:

b5:

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f2a:

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3s:

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1:

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36…