Appendix A_.pdf

December 8, 2020 VHA DIRECTIVE 0730(1)

APPENDIX A

AUTHORIZATION FORM FOR PSYCHOLOGICAL EVALUATION

Applicant/Incumbent Name:

Date of Birth:

Social Security Number (last 4 numbers):

The following information is provided to allow full disclosure of the purpose of this evaluation and the rights you have in this evaluation process.

PURPOSE OF PSYCHOLOGICAL EVALUATION

Each applicant or incumbent Department of Veterans Affairs (VA) Police Officer is required to successfully complete a psychological evaluation prior to employment and as part of the periodic medical evaluation.

The purpose of this psychological evaluation is to provide information to the Employee Occupational Health (EON) Agenc), Medical Officer about your suitability and emotional stability, both of which have been determined to be essential to performing the duties of a VA Police Officer. This evaluation will assist the EOH Agency Medical Officer in recommending hiring or retention as a VA Police Officer. This psychological evaluation is not for counseling or health care purposes. The findings concerning your psychological qualifications for suitability as a VA Police Officer are not a statement of opinion about your general psychological health, or your suitability as a Police Officer with a different agency, or suitability for a different oosition within VA. This psychological evaluation is not intended for any use other than its stated purpose of evaluating your qualifications for employment as a VA Police Officer.

This psychological evaluation may consist of taking psychometric tests. You will be answering questions in written or computer administered examinations that will measure your psychological characteristics.

Additionally, you will participate in a clinical interview. This will include questions about relevant employment, educational, or behavioral experiences and you may be asked about your responses to test questions in order to aid in test in:erpretation.

You have the right to terminate this process at any time, although your refusal to complete this evaluation could result in withdrawal of an offer of employment, if you are an applicant, or administrative or personnel action if you are an incumbent VA Police Officer.

INTENDED RECIPIENT OF PSYCHOLOGICAL EVALUATION

All psychological test materials, tes: data, and personal information you provide will be the property of VA. The psychologist or psychiatrist performing this evaluation is employed by or under contract with VA. The psychologist or psychiatrist findings are disclosed to the VA

A-1 medical facility EOH Agency Medical Officer only. The EOH Agency Medical Officer is responsible for providing the final recommendation regarding employment to VHA Human Resources.

FEES

VA will pay all fees connected with your referral for psychological evaluation services. VA does not cover the cost of any other reports or information you would like to provide to the VA psychologist or psychiatrist or EOH Agency Medical Officer.

PROFESSIONAL RELATIONSHIPS

You have the right to be treated in a professional, respectful manner. The primary responsibility of your examining psychologist or psychiatrist is to the VA. Your psychological evaluation is part of an evaluation for fitness for duty and is not considered treatment as part of an established doctor-patient relationship. Your confidentiality and its limits described below and are different than in a treatment relationship with a doctor. You will not be given any feedback or a copy of your evaluation results unless requested by filling out VHA Form 10-5345 and VHA Form 10-5345, Request for and Authorization to Release Health Information.

The examining psychologist or psychiatrist may consult with other health and mental health providers. The other provide-s are legally and ethically bound to keep the information confidential.

The psychologist or psychiatrist, whether employed or contracted by VA, is working for the VA and the primary responsibility is to VA.

CONFIDENTIALITY AND RELEASE OF INFORMATION

The psychological evaluation will be used as one of several elements to determine your qualifications for this position and whether or not you will be hired or retained as a VA Police Officer.

All of the information obtained from this psychological evaluation belongs to VA. Results of your evaluation will not become part of your personnel file. Your psychological evaluation will be safeguarded with due regard to your personal privacy.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.

To comply with this law, we ask that you not provide any genetic information when responding to this request for medical information. "Genetic information," as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or ar embryo lawfully held by an individual or family member receiving assistive reproductive services.

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A report of this evaluation, including pertinent findings and conclusions and the professional opinion as to your qualifications for this position, will be provided to the EOH Agency Medical Officer. If there are indications of any mental or emotional disorders or maladaptive behavioral patterns which could significantly interfere with your ability to safely and effectively perform the duties of a VA Police Officer, or if you are not truthful while participating in this evaluatior, your conditional job offer or continued employment as a VA Police Officer may be withdrawn.

The recommendation report generated will contain the minimum amount of information to achieve the intended purpose to satisfy the requirements of evaluation and support its findings, conclusions, and recommendations.

The report will be provided only to the VA medical facility EOH Agency Medical Officer.

Information will not be released to other sources except as required by law or with your authorization with certain exceptions. Some of the circumstances in which the examining psychologist or psychiatrist has a legal duty to release information include, but are not limited to: abuse of children or other vulnerable persons; threats of harm to others, the examining psychologist or psychiat-ist, or yourself; upon binding court order or in the process of a lawsuit; and where disclosure is required by State or Federal law.

In addition, results may be used in validating the screening process, teaching, and research or development of police psychological screening procedures. If used in such ways, your name or personally identifying formation will not be associated with results or otherwise disclosed.

DISCLOSURE ACKNOWLEDGMENT AND RELEASE

• I have read and understand the information in this Authorization Form.

• I give my authorization to participate in this psychological evaluation.

• I understand that confidentiality will be maintained. I understand that this psychological evaluation is cnly one component of a larger process in determining my qualifications for employment as a VA Police Officer.

• I understand this evaluation s not for the purpose of evaluating any mental health conditions.

• I further understand that the examining psychologist or psychiatrist will provide a recommendation report to the VA medical facility EOH Agency Medical Officer as to my qualifications for employment as a VA Police Officer.

• I understand this report is the property of the Office of Personnel Management and is under the custody of the VA medical facility EOH.

• I release the examining psychologist or psychiatrist from all liability or claims of damage associated with furrishing this report to the VA medical facility EOH Agency Medical Officer, including the opinions and recommendations of the examining psychologist or psychiatrist.

• I authorize the examining psychologist or psychiatrist to use and disclose the findings as to my psychologbal qualification, suitability, or fitness for the position of a VA Police Officer to the VA medical facility EOH Agency Medical Officer.

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• I do not need to sign this authorization. However, my refusal will mean that the required psychological evaluation will not take place. This fact may have implications for my employment as a VA Police Officer.

QUESTIONS

Should you have any additional questions or concerns about the psychological evaluation, you may direct them to the evaluator conducting this evaluation or the VA medical facility EOH Medical Officer.

Your signature below indicates that you have read and understood the terms above, and that you are choosing to proceed with your participation in the evaluation as described above.

Print Name:

Signature: Date:

Examiner Signature: Date:

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