Required VA Documents

Additional Programs.

REQUIRED VA DOCUMENTS 

A complete packet of forms must be sent to the service point of contact at the VA for the service in which you have chosen to rotate four weeks prior to the start of the rotation.  Failure to meet the four week deadline will necessitate choosing another rotation or having your rotation delayer.  See the Application Checklist for forms and complete all as required.

The VA Packet may be scanned and emailed securely to the appropriate VA contact or mailed via US mail.

Application Checklist for Associated Health Trainees

Statement of Commitment and Understanding

Orientation Handbook – Signature Page

TMS Self Enrollment Training Instructions

VACCHS Handbook

SF 61

VA Form 10-2850 Application for Health Professions Trainees 

  • complete form and sign/date pages 3 and 4; designated POC in the service where student will train must complete: 12A, 12B, and 12C on page 1

Fingerprint Appointment Schedule

PIV Data Sheet

Fingerprint Request Form

VA Computer Access Form

Without Compensation (WOC) Assignment Letter (MS word doc) – to be filled in by staff at UCSF Fresno and signed by the student.  Return with VA packet.

You will be asked to complete the OF 306 Declaration for Federal Employment and the USCIS I-9 Employment Eligibility Verification forms in the PIV Office at the Fresno VA.

Contact List – Veteran’s Administration Health System, Fresno CA

  • Dermatology (Hamlin/Simpson)—Contact for Without Compensation Appointment onboarding:  Michelle Nunez (559-225-6100 x 5417 or Michelle.Nunez@va.gov
  • Rheumatology ( Majmudar/Yuvienco )–Contact for Without Compensation Appointment onboarding:  Michelle Nunez (559-225-6100 x 5417 or Michelle.Nunez@va.gov
  • Neurology (Ryan/Mogelof)—Contact for Without Compensation Appointment onboarding:  Michelle Nunez (559-225-6100 x 5417 or Michelle.Nunez@va.gov
  • Core Medicine—Contact for Without Compensation Appointment onboarding: Michelle Nunez (559-225-6100 x 5417 or Michelle.Nunez@va.gov
  • Endocrinology (Ginier)–Contact for Without Compensation Appointment onboarding: Heather Garner (559-225-6100 x 3789 or Heather.Garner@va.gov
  • Psychiatry (Howsepian)– Contact for Without Compensation Appointment onboarding:  Andrea Willis (559-225-6100 x 6327 or Andrea.Willis@va.gov
  • Radiology (Anderson)– Contact for Without Compensation Appointment onboarding:  Amelinda Bowman (559-225-6100 x 5814 or Amelinda.Bowman@va.gov

TQCVL Letter & Administrator – Pam Utter (559) 225-6100 x5657 (Pamela.Utter@va.gov )
Fingerprints – Lamont Chaney (559) 225-6100 x5884 (Lamont.Chaney@va.gov)
VA Mail Group:  V21FREMedicalStudentServiceCoordinators@va.gov