Duke Residents
Congratulations on your new appointment as a Duke Resident at the Durham VA Health Care System. We are excited to have you on the team. We hope your time with us is both exciting and motivating. Below you will find links to the paperwork required for Duke Residents. Complete, print out, sign and turn in all paperwork together to your points of contact identified below. Again, congratulations and welcome to the team.
Duke Residents
Items listed below must be received by the Durham VAHCS NLT April 30, 2021:
Mailing Address:
Durham VA Medical Center
Duke Residency
Durham VA Medical Center [insert mail code from Point of Contact document]
Attn: [insert name of DVAHCS point of contact from the Point of Contact document]
508 Fulton Street
Durham, North Carolina 27705
(Please download each document to your computer in order to edit and input your information.)
VA Form 10-2850D Application for Health Professions Trainee Dated Nov 2011
INSTRUCTIONS FOR COMPLETING THE VA FORM 10-2850D
Page 1
1 A. Name – (Provide FIRST, FULL MIDDLE, & LAST NAME). If you don’t have a middle name, indicate “No Middle Name”. If you have only initials in your name, provide them and indicate “Initial only”.
- Complete maiden names, nick names, other spellings, or name changes
- Address - Complete address to include zip code
3A &3B. Telephone – Telephone number to include area code for morning and evening
- Social Security # - Complete 9-digit social security number
5A. Primary Email Address – Best email address to reach you
5B. Alternate Email Address -
- Date of Birth – Month, Day, and Year of birth
- Training Facility (City, State) – Durham, NC
7B& 7C – check the unknown box
8A – Are you now in the U.S. Military – select the response that applies to you
8B. Are you in the Reserves of National Guard? – select the response that applies to you
8C. Branch of Service – enter as appropriate or enter N/A or None
8D. Start Date of your Degree, Month and Year
9A. Enter citizenship status
9B. Enter your country of citizenship
Complete items 10A, 10B, 10C and 10D only if you are not a US Citizen
Page 2
(Please provide your complete name & SSN at top of the page)
Item V
Current Clinical License or Certifications – Complete all fields, if none, N/A or None
Item VI
Previous Clinical License or Certifications - Complete all fields, if none, N/A or None
15 – enter your National Provider Identifier (NPI)
16 – complete
17 – complete
Item VII – Education and Training
18 A – Enter all schools after high school in chronological order
18B – Enter address of schools
18C – Enter start date for program
18D – completion date
18E – Diploma earned
18F – Field of Study
Item VIII
International Graduates – If you are an international student, complete all fields
Item IX
Internship, Residency, and Fellowship – If apply, complete all fields with full name of school and complete physical address WITH City, State and Zip or N/A or None
Page 3
(Please provide your complete name & SSN at top of Pages 2-4. Sign pages 3 & 4.
Item X
Respond to questions 21, 22 & 23
Item XI
Additional space for previous responses
Sign and date page 3 at the bottom of the form
Page 4
(Please provide your complete name & SSN at top of Pages 2-4. Sign pages 3 & 4)
Authorization for Release of Information – Read and Check all boxes, date, sign and read privacy notice Name and Social Security number should be on top of every page where specified
Sign and date page 4
Form (OF) 306, Declaration for Federal Employment
Instructions for completion of the OF-306:
- (Provide FIRST NAME, FULL MIDDLE NAME, & LAST NAME). If you don’t have a middle name, indicate “No Middle Name”. If you have only initials in your name, provide them and indicate “Initial only”
- Social security number
- Place of birth
- U.S. citizenship status
- Date of birth
- Other names ever used- Complete maiden names, nick names, other spellings, or name changes
- Phone numbers
- Selective service registration
- Background information about convictions, firings, delinquent federal debt
- Whether your relatives work for the agency or government organization to which you are submitting this form
- Whether you receive or have ever applied for retirement pay, pension, or other retired pay based on military, federal civilian or District of Columbia Government service
- Signature (Sign as applicant)
- Date
- Date you left last federal job if any
- Whether you waived basic life insurance or any type of optional life insurance when you last worked for the federal government, whether you later cancelled that waiver
Courtesy Fingerprints
Courtesy Fingerprinting: You must contact a nearby VA, to begin the fingerprint clearance process prior to arriving in Durham (Present the DVAMC Appointment letter and the Courtesy fingerprints document to your Local VA Facility. Locations for courtesy fingerprints can be found at https://www.oit.va.gov/programs/piv/locations.cfm
Advise your DVAHCS POC when and where courtesy prints were taken. Do not hesitate to complete this requirement
Mandatory Training
VHA Mandatory Training for Trainees (MTT): must be completed prior to submitting paperwork Go to TMS website-Self register and complete MTT. You need the following information to complete self-registration:
VA Location: DUR
Provide a copy of your course completion to your DVAHCS POC when you submit your paperwork
*Trainees who previously had TMS accounts: Change your email accounts in TMS to ensure you can access the email account listed. If you previously had a TMS account and can no longer access it, please send an email to VHADURTMSDOMAINMANAGERS@va.gov requesting assistance
Current PIV Badge Holders
If you have a PIV badge from another VA facility, please advise your DVAHCS POC.
Personal Identity Verification (PIV) (Submit a copy of your social security card and driver's license, state ID or VISA to your DVAHCS POC NLT April 30, 2021). Please notify POC of any changes to Driver’s License, State ID or VISA prior to orientation.
Lost, Stolen, Destroyed, or Damaged PIV Badge (If previously issued a PIV badge that has been lost, stolen, or destroyed, please fill out the PIV Memo through your signature line. Return document your DVAHCS POC)
NPI Number
NPI Number (Include your NPI number on your VA Form 10-2850 and print page with NPI Number and send page to your DVAHCS POC)