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6 SPECIAL AGREEMENT CHECK (SAC) OFI Form 86C July 2005 Agreement Number: OPM Use Only: OPM Codes: Case Number: U.S Office of Personnel Management Center for Federal Investigation Services Agency use oniy (complete items 1 through 14 using instructions from the back) 1. Subject s Full Name 2. Date of Birth Last Name First Name Middle Name (at birth) Month Day Year 3. Place of Birth 4. SSN City County State Country 5. Other Names Used and Dates When Used - Name From From Name From From Month Year Month Year Month Year Month Year Name From From Name From From Month Year Month Year Month Year Month Year 6. Sex (1Iark one box) 7. Special Agreement Code 8. Position Title LI Female LI Male 9. SON 10. SOI 11. OPAC-ALCNuinber 12. Accounting Data V A Name and Title of Requesting Official Signature of Requesting Official Telephone Number Date X6306

11 VAMC FINGERPRINTING INSTRUCTIONS Fingerprinting is a critical security prerequisite for working at a VA facility and should be completed as soon as possible. Please read these instructions carefully: For trainees who live near the Atlanta VAMC or plan to be in the area before reporting in June: 1. Complete the form Electronic Fingerprint Submission Form and submit it with all your other application documents 2. Contact the Atlanta VAMC fingerprinting office to schedule a fingerprinting appointment: Fingerprinting Office Phone Number: (555) Standard Fingerprinting Hours of Operation: M-F 8:00-5:00 3. Bring two acceptable and original forms of identification to your scheduled fingerprinting appointment along with a copy of your Electronic Fingerprint Submission Form. For information about acceptable forms of identification, please visit the following web address: For trainees who DO NOT live near the Atlanta VAMC or plan to be in the area before reporting in June: 1. Complete the form Electronic Fingerprint Submission Form and submit it with all your other application documents 2. Contact your nearest VA Medical Center and request an appointment to complete your fingerprinting For a list of VA locations and Fingerprinting/Badge Office contact numbers, please visit the following web-address: (Note: Different VA facilities complete fingerprinting in different areas. Please ask to be directed to the fingerprinting location at the VA you contact if the number on the website does not lead you directly to this location). 3. Complete section A of the form titled Government and Affiliates/Non-Contractors Special Agreement Check (SAC) Fingerprint Request Worksheet. (Section B should be pre-populated*). 4. Bring the following to your fingerprinting appointment: Two acceptable and original forms of identification. For Information about acceptable forms of identification, please visit the following web address: The form titled Government and Affiliates/Non-Contractors Special Agreement Check (SAC) Fingerprint Request Worksheet. For trainees who are unable to obtain fingerprints prior to your program reporting date: Please complete and submit your application packet including the form titled Electronic Fingerprint Submission Form. Opportunities for fingerprinting will available after you report in to your training program in June but may detract from your orientation or lead to delays in starting your VA clinical rotations. For trainees without a Social Security Number: Please contact the Education Office in Atlanta at: (404)

12 Electronic Fingerprint Submission Form Last Name First Name Middle Name Social Security # Date of Birth Sex Male Female Race Height Weight Eye Color Hair Color Place of Birth (City & State) Home Address Citizenship Employer Scars, Marks, Tattoos If you were fingerprinted or have an appointment to be fingerprinted at a VAMC location other than Atlanta, enter the facility name and contact number here.

Government and Affiliates/Non-Contractors Special Agreement Check (SAC) Fingerprint Request Worksheet Part A Individual s Data (completed by the Individual being fingerprinted) Employee (Full Name):

13 Government and Affiliates/Non-Contractors Special Agreement Check (SAC) Fingerprint Request Worksheet Part A Individual s Data (completed by the Individual being fingerprinted) Employee (Full Name): Employee Social Security No.: Part B Requesting Office Data (completed by the Requesting office) Facility: Atlanta VAMC Address: 1670 Clairmont Road, Decatur, GA Contact Name: Dr. John Doe Contact Phone: (404) Contact John.Doe@VA.gov Contact Fax: (404) Submitting Office No. (SON): Security Office Identifier (SOI): Part C Submitting Office Data (completed by the Submitting Office) Facility: Address: Contact Name: Contact Phone: Contact Contact Fax: Part D Transmission/Release Method (check one) (completed by Submitting Office) FTS electronic submission using Requesting Office SON/SOI or Submitting Office s SON/SOI SF-87 printed and mailed to OPM-FIS SF-87 printed and released to Individual Part E Purpose of the Request (check one) (completed by Requesting Office) Federal Applicant/Volunteer/Health Professional Trainee/etc. Screening OPM Investigation Requirement PIV/Non-PIV Card Requirement *** Submitting Office will return this form to the requesting office contact identified in Part B above. Form will be returned by secure means to safeguard Personally Identifiable Information (PII). Submitting Office should retain a copy for their records. VA Security Specialist Date/Time

Talent Management System User Job Aid: Create New non-va User Record Purpose The purpose of this job aid is to guide users through the step-by-step process of creating the Create New User tool in the

14 Talent Management System User Job Aid: Create New non-va User Record Purpose The purpose of this job aid is to guide users through the step-by-step process of creating the Create New User tool in the VA TMS. In this job aid you will learn how to: A. Create New User Record 9 Steps B. Complete Required Training 6 Steps Task A. Go to to Create New User Record 1 Step 1 From the Login page, in the brown navigation bar click the Create New User link Step 2 In the VA TMS Self Enrollment page, select the appropriate employment type. Step 3 Click Next

4a Step 4a If you are a foreign national, click the click here link. 4a 4 4b Step 4b If there is a security pop-up click Allow.

15 Talent Management System 4 Step 4 In My Account Information section, fill in all required fields as noted by the red asterisk, taking care to type accurately when entering your Social Security Number, address, and legal name; proceed to Step 5. 4a Step 4a If you are a foreign national, click the click here link. 4a 4 4b Step 4b If there is a security pop-up click Allow. 4c Step 4c In the pop-up add any additional information to assist the Admin like your name and contact information and click Send. 4b 4c - 2 -

16 Talent Management System 5 Step 5 In My Job Information section, fill in all required fields as noted by the red asterisk, entering the data provided by your VA point of contact where appropriate. 5 VA City: Decatur VA State: GA VA Location Code: ATG 6 VA POC: Choose from list attached Choose from list attached Phone Step 6 7 If you are required to take training on the Health Insurance Portability and Accountability Act (HIPPA), click the box. 8 Step 7 Click Submit. Step 8 From the congratulations page, note your VA TMS USER ID for future use. 8 9 Step 9 Click Continue

hover over item in your To Do List to display the pop-up

3 Step 3 Complete training per instructions.

17 Talent Management System Task B. Complete Required Training 1 Step 1 From the Home page, hover over item in your To Do List to display the pop-up menu Step 2 Click Go to Content. 3 Step 3 Complete training per instructions. 4 Step 4 On the Online Content Structure page, click the Completed Work link Step 5 From the Completed Work page, hover over the title of the completed training to display the pop-up menu. Step 6 Click Print Certificate

18 Talent Management System Program Coordinator/Director Name Specialty/Subspecialty Address Walid Nassif, MD, Psychiatry Addiction psychiatry David Fishman, MD, Chief, Anesthesiology Anesthesiology Maziar Zafari, MD, CCU Director, Cardiology Cardiovascular disease Benjamin Hunter, DDS, Chief, Dental Dentistry - Oral and Maxillofacial Surgery Benjamin.hunter@va.gov Robert Swerlick, MD, Program Director, Dermatology Dermatology robert.swerlick@va.gov Peter Thule, MD, Program Director Endocrinology, diabetes, and metabolism peter.thule@va.gov Kimberly House, MD, Chief, NHCU Family medicine kim.house@va.gov Shanti Srinivasan, MD, Chief, Gastroenterology Gastroenterology shanti.srinivasan@va.gov Anna Mirk, MD, Geriatric Fellowship Geriatric medicine anna.mirk@va.gov Walid Nassif, MD, Psychiatry Geriatric psychiatry walid.nassif@va.gov Maria Ribeiro, MD, Chief, Hematology/Oncology Hematology and Oncology maria.robeiro@va.gov Tammie Quest, MD, Chief of Hospice and Palliative Care Hospice and Palliative Care tammie.quest@va.gov Abeer Moanna, MD, Chief, Infectious Diseases Infectious Disease abeer.moanna@va.gov Shahed Brown, MD, Associate Program Director Internal medicine shahed.brown@va.gov James White, MD, VA Coordinator- Fort MacPherson CBOC Internal medicine james.white17@va.gov Kreton Mavromatis, M.D., AVAMC Chief of Interventional Cardiology Interventional cardiology kreton.mavromatis@va.gov Lynn Schlanger, MD, Chief, Nephrology Nephrology lynn.schlanger@va.gov William Tyor, MD, Chief, Neurology Neurology william.tyor@va.gov Scott Bartley, MD, Chief, Nuclear Medicine Nuclear medicine scott.bartley@va.gov Jennifer Goedken, MD, Chief, Gynecology Obstetrics and gynecology jennifer.goedken@va.gov D'Nyce Williams, MD, Women's Health COE Director Obstetrics and gynecology d'nyce.williams@va.gov Steven Urken, MD, Chief, Ophthalmology Ophthalmology steven.urken@va.gov John Louis-Ugbo, MD, Interim Chief, Orthopaedics Orthopaedic surgery John.louis-ugbo@va.gov Carrie Flanagan, MD, Chief, Otolarynology Otolaryngology carrie.flanagan@va.gov Craig Campus, MD, Acting Chief, Laboratory & Pathology Pathology-Anatomic and Clinical craig.campus@va.gov Laura Lee, MD, MBA, Chief, PM&R Physical medicine and rehabilitation laura.lee@va.gov - 5 -

19 Talent Management System Mark Walsh, MD, Interim Chief, Plastic Surgery Plastic surgery Angel Jimenez, DPM, Program Director Podiatry Surgery Yvette Williams, MD, MPH, VISN 7 Physician Preventive medicine christine.williams@va.gov Walid Nassif, MD, Psychiatry Psychiatry walid.nassif@va.gov Walid Nassif, MD, Psychiatry Psychosomatic Medicine farooq.amin@va.gov Ruxana Sadikot, MD, Associate Program Director, Pulmonary/CCM Fellowship Pulmonary disease and critical care medicine ruxana.sadikot@va.gov Bruce Hershatter, MD, Chief, Radiation Oncology Radiation oncology bruce.hershatter@va.gov Ronald Mixon, MD, Assistant Chief, Radiology Radiology-diagnostic ronald.mixon@va.gov Karen Atkinson, MD, Chief, Rheumatology Rheumatology karen.atkinson@va.gov Octavian Ioachimescu, MD, Sleep Medicine Physician Sleep Medicine octavian.ioachimescu@va.gov Jackson Slappy, MD, Staff Physician, Surgery Surgery-general ashley.slappy@va.gov Felix Fernandez, MD, Staff Physician, Thoracic Surgery Thoracic surgery felix.fernandez@va.gov Stephanie Brown-Johnson, MD, Primary Care Physician Transitional year stephanie.brown-johnson@va.gov Muta Issa, MD, Chief, Urology Urology muta.issa@va.gov Ronald Mixon, M.D. Interventional Radiology Vascular and interventional radiology ronald.mixon@va.gov Atef Salam, MD, Chief, Vascular Surgery Vascular surgery atef.salam@va.gov - 6 -

AVMED SPECIALIST/SPECIALTIES REQUIRING MEDICARE REFERRAL

AVMED SPECIALIST/SPECIALTIES REQUIRING MEDICARE REFERRAL Addiction Psychiatry Adolescent Medicine (Family Practice) Adolescent Medicine (Pediatric) Adult Congenital Heart Disease Advanced Heart Failure and Transplant Cardiology Aerospace Medicine Allergy & Immunology