System of Records (SOR)

08VA05 - Employee Medical File System Records (Title 38)-VA

System location:
For current employees, records are located in VA medical, personnel, dispensary, health, safety or other designated offices at Central Office and field facilities (see Appendix 1); with another agency providing such services for the VA; or with private sector contractors. For former employees, most records will be located in an Employee Medical Folder (EMF) stored in Federal records centers operated by the National Archives and Records Administration (NARA). Paper record abstract information is stored in automated storage media records that are maintained at the health care facilities.

Categories of individuals covered by the system:
The following categories of individuals are covered by this system: current or former VA employees appointed under 38 U.S.C. Chapter 73 to the occupations identified in 38 U.S.C. 4103, 4104(1), and 4104(3); individuals in those occupations who are appointed under 38 U.S.C. 4114; and residents appointed under 38 U.S.C. 4114(b). This includes employees such as non-physician facility Directors, physicians, dentists, podiatrists, optometrists, nurses, nurse anesthetists, physician assistants, expanded-function dental auxiliaries, certified respiratory therapy technicians, registered respiratory therapists, licensed physical therapists, and licensed practical or vocational nurses. Current and former employees appointed under 38 U.S.C. Chapter 75 in the Veterans Canteen Service are also covered.

Categories of records in the system:
Records maintained in this system include: (1) Medical records, forms, and reports completed or obtained when an individual applies for a Federal job and is subsequently employed; (2) Medical records, forms, and reports completed during employment as a condition of employment, either by the VA or by another agency, State or local government entity, or a private sector entity under contract to the VA; (3) Records resulting from the testing of the employee for use of illegal drugs under Executive Order 12564. Such records may be retained by the VA (e.g., by the VA Medical Review Official) or by a contractor laboratory. This includes records of negative results, confirmed or unconfirmed positive test results, and lists of who has been tested, who failed to report for testing, and related documents. Records maintained by a VA dispensary are included in the system only when they are the result of a condition of employment or related to an on-the-job occurrence. (4) Files containing reports of on-the-job injuries and medical records, forms, and reports generated as a result of the filing of a claim for Workers' Compensation, whether the claim is accepted or not. (The official compensation claim file, maintained by the Department of Labor's Office of Workers' Compensation Program (OWCP) is part of that agency's system of records and not covered by this notice.) (5) All other medical records, forms, and reports created on an employee during his or her period of employment, including records retained on a short term/ temporary basis (i.e., those designated to be retained only while the employee is with the VA) and records designated for long-term retention (i.e., those retained for the employee's duration of Federal service and for some period of time thereafter).

Authority for maintenance of the system:
Executive Order 12564; Urgent Relief for the Homeless Supplemental Appropriations Act of 1987, Pub. L. No. 100-71, Section 503, 101 Stat. 468 (1987); and Title 38, United States Code, Chapter 3, Section 210(c)(1,); Chapter 73, Section 4108 and Chapter 75, Section 4202.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses:

Except for Routine Use 7, no other Routine Use for this system of records applies to records included in Item (3) in the Categories of Records in the System section of this notice. Drug test results may not be released under any other routine use.

1. In the event that a system of records maintained by this agency to carry out its function indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature and whether arising by general statute or particular program statute, or by regulation, rule or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the appropriate agency, whether Federal, State, local or foreign, charged with the responsibility of investigation or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation or order issued pursuant thereto.
2. To assess physical capability of employees and to provide data for periodic reports of the health services program to the Civil Service Commission.
3. Information may be disclosed from this system of records to a Federal, State, or local agency to the extent necessary to comply with laws governing reporting of communicable diseases.
4. Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
5. Disclosure may be made to NARA (National Archives and Records Administration) GSA (General Services Administration) in records management inspections conducted under authority of 44 U.S.C. 2904 and 2906.
6. To disclose information to the Department of Labor, Social Security Administration, or a national, State, or local social security type agency, when necessary to adjudicate a claim (filed by or on behalf of the individual) under a retirement, insurance, or health benefit program.
7. To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, either when the Government is a party to a judicial proceeding or to comply with the issuance of a subpoena.
8. To disclose the results of a drug test of a Title 38 employee pursuant to an order of a court of competent jurisdiction where required by the United States Government to defend against any challenge against any adverse personnel action.
9. To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which the VA is authorized to appear, when: (a) The VA, or any component thereof; or (b) any VA employee in his or her official capacity; or (c) any VA employee in his or her individual capacity where the Department of Justice or the VA has agreed to represent the employee; or (d) the United States, where the VA determines that litigation is likely to affect the VA or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or the VA is deemed by the VA to be relevant and necessary to the litigation, provided, however, that in each case it has been determined that the disclosure is compatible with the purpose for which the records were collected.
10. To disclose in response to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a pending judicial or administrative proceeding.
11. To disclose pertinent information to the appropriate Federal, State or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order when the disclosing agency becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
12. To disclose information to the Office of Management and Budget (OMB) at any stage in the legislative coordintion and clearance process in connection with private relief legislation as set forth in OMB Circular No. A-19.
13. To disclose information to officials of the Merit Systems Protection Board including the Office of Special Counsel, the Federal Labor Relations Authority and its general counsel, the Equal Employment Opportunity Commission, arbitrators, and hearing examiners to the extent necessary to carry out their authorized duties.
14. To disclose information to survey team members from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) when requested in connection with an accreditation review, but only to the extent that the information is relevant and necessary to meet JCAHO standards.
15. To disclose to health insurance carriers contracting with the Office of Personnel Management to provide a health benefits plan under the Federal Employee Health Benefits Program, information necessary to verify eligibility for payment of a claim for health benefits or to carry out the coordination of audit of benefit provisions of such contracts.
16. To locate individuals for health research or survey response and in the production of summary descriptive statistics and analytical studies (e.g., epidemiological studies) in support of the function for which the records are collected and maintained. While published statistics and studies do not contain individual identifiers, in some instances the selection of elements of data included in the study might be structured in such a way as to make the data individually identifiable by inference.
17. To disclose information to the Office of Federal Employees Group Life Insurance that is relevant and necessary to verify election, declination, or waiver of regular and/or optional life insurance coverage or eligibility for payment of a claim for life insurance.
18. To disclose information, when an individual to whom a record pertains is mentally incompetent or under other legal disability, to any person who is responsible for the care of the individual, to the extent necessary.
19. To disclose to the agency-appointed representative of an employee all notices, determinations, decisions, or other written communications issued to the employee, in connection with an examination ordered by the agency under: (a) Medical evaluation (formerly Fitness for Duty) examinations procedures, or (b) agency- filed disability retirement procedures.
20. To disclose to a requesting agency, organization, or individual the home address and other information concerning those individuals who it is reasonably believed might have contracted an illness or been exposed to or suffered from a health hazard while employed in the Federal work force.
21. To disclose information to a Federal agency, in response to its request or at the initiation of the VA, in connection with the retention of an employee, the issuance of a security clearance, the conducting of a suitability or security investigation of an individual, the letting of a contract, or the issuance of a license, grant, or other benefit by the other agency, or the lawful statutory, administrative or investigative purpose of the agency to the extent that the information is relevant and necessary to the other agency's decision on the matter.
22. To disclose to any Federal, State, or local government agency, in response to its request or at the initiation of the VA, information relevant and necessary to the lawful, statutory, administrative, or investigatory purpose as it relates to the conduct of job related epidemiological research or the assurance of compliance with Federal, State, or local government laws on health and safety in the work environment.
23. To disclose to officials of labor organizations recognized under 5 U.S.C. Chapter 71, analyses using exposure or medical records and employee exposure records, in accordance with the record access rules of the OSHA, Department of Labor, and subject to the limitations of 29 CFR 1910.20(e)(2)(iii)(B).
24. Records from this system of records may be disclosed to a Federal Agency or to a State or local government licensing board and/ or to the Federation of State Medical Boards or a similar nongovernment entity which maintains records concerning individuals' employment histories or concerning the issuance, retention or revocation of licenses, certifications, or registrations necessary to practice an occupation, profession or specialty, in order for the Agency to obtain information relevant to an Agency decision concerning the hiring, retention or termination of an employee or to inform a Federal Agency or licensing boards or the appropriate nongovernment entities about the health care practices of a terminated, resigned or retired health care employee whose professional health care activity so significantly failed to conform to generally accepted standards of professional medical practice as to raise reasonable concern for the health and safety of patients in the private sector or from another Federal Agency. These records may also be disclosed as part of an ongoing computer matching program to accomplish these purposes.
25. Information in this system of records may be disclosed to a State or local government entity which has the legal authority to make decisions concerning the issuance, retention or revocation of licenses, certifications or registrations required to practice a health care profession, when requested in writing by an investigator or supervisory official of the licensing entity for the purpose of making a decision concerning the issuance, retention or revocation of the license, certification or registration of a named health care professional.
26. Identifying information in this system, including name, address, social security number and other information as is reasonably necessary to identify such individual, may be disclosed to the National Practitioner Data Bank at the time of hiring and/or clinical privileging/reprivileging of health care practitioners, and other times as deemed necessary by VA, in order for VA to obtain information relevant to a Department decision concerning the hiring, privileging/reprivileging, retention or termination of the applicant or employee.
27. Relevant information from this system of records may be disclosed to the National Practitioner Data Bank and/or State Licensing Board in the State(s) in which a practitioner is licensed, in which the VA facility is located, and/or in which an act or omission occurred upon which a medical malpractice claim was based when VA reports information concerning: (1) Any payment for the benefit of a physician, dentist, or other licensed health care practitioner which was made as the result of a settlement or judgment of a claim of medical malpractice if an appropriate determination is made in accordance with agency policy that payment was related to substandard care, professional incompetence or professional misconduct on the part of the individual; (2) a final decision which relates to possible incompetence or improper professional conduct that adversely affects the clinical privileges of a physician or dentist for a period longer than 30 days; or, (3) the acceptance of the surrender of clinical privileges or any restriction of such privileges by a physician or dentist either while under investigation by the health care entity relating to possible incompetence or improper professional conduct, or in return for not conducting such an investigation or proceeding. These records may also be disclosed as part of a computer matching program to accomplish these purposes.

Policies and practices for storing, retrieving, accessing, retaining, and disposing of records in the system:

Storage:
Records are stored in paper folders, microfiche, magnetic discs, magnetic tape, and on file cards, X-rays, or other medical reports and forms. These records are stored in VA medical, personnel, dispensary, health, safety or other designated offices at Central Office and field facilities. Information in the Decentralized Hospital Computer Program (DHCP) system is stored at health care facilities.

Retrievability:
Records are retrieved by the employee's name, date of birth, social security number, or any combination of those identifiers.

Safeguards:
Records are stored in locked file cabinets or locked rooms. Generally, file areas are locked after normal duty hours. Automated records are protected by restricted access procedures and audit trails. Access to Employee Medical File System records is strictly lilmited to VA or contractor officials with a bona fide need for access to the records. Strict control measures are enforced to ensure that access to and disclosure from these records are limited to a ``need-to-know basis.'' In VA Central Office these records are maintained in staffed rooms during working hours. During nonworking hours, there is limited access to the building with visitor control by security personnel. Access to the DHCP computer rooms within the health care facilities is generally limited by appropriate locking devices and restricted to authorized VA employees and vendor personnel. Automated data processing peripheral devices are generally placed in secure areas (areas that are locked or have limited access) or are otherwise protected. Information in the DHCP system may be accessed by authorized VA employees. Access to file information is controlled at two levels; the system recognizes authorized employees by a series of individually unique passwords/codes as a part of each data message, and the employees are limited to only that information in the file which is needed in the performance of their official duties. Drug testing records will be maintained in accordance with the Urgent Relief for the Homeless Supplemental Appropriations Act of 1987, Pub. L. No. 100-71, Section 503, 101 Stat. 468 (1987). Contractor laboratories are subject to the same restrictions as VA employees.

Retention and disposal:
Records are retained in accordance with records retention standards approved by the Archivist of the United States, the National Archives and Records Administration, and published in Agency Records Control Schedules. Records arising in connection with employee drug testing under Executive Order 12564 are generally retained for up to 2 years. Records are destroyed by shredding, burning, or by erasing the magnetic media. Automated storage media is retained and disposed of in accordance with disposition authorization approved by the Archivist of the United States.

System manager(s) and address:
Director, Office of Personnel and Labor Relations (05), VA Central Office, 810 Vermont Avenue NW, Washington, DC 20420.

Notification procedure:
Individuals wishing to inquire whether this sytem of records contains records on them should follow the appropriate procedure listed below.

1. Current employees. Current employees should contact the local facility at which they are employed. Individuals must furnish such identifying information as required by VA for their records to be located and identified.
2. Former employees. Former employees should contact the local facility at which they were employed. Individuals submitting requests must submit the following information for their records to be located and identified: (1) Full name, (2) date of birth, (3) social security number, (4) name and location of VA facility where last employed and dates of employment, and (5) signature.

Record access procedures:
Individuals requesting access to and contesting the contents of records must submit the following information for their records to be located and identified: (1) Full name, (2) date of birth, (3) social security number, (4) name and location of VA facility where last employed and dates of employment, and (5) signature.

Contesting record procedures:
(See Record Access Procedures above).

Record source categories:
Records in this system are obtained from: The individual to whom the records pertain, VA employee health unit staff, Federal and private sector medical practitioners and treatment facilities, supervisors/managers and other VA officials, testimony of witness, and other VA records.

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