SPECIAL AGREEMENT CHECK (SAC)

OFI Form 86C U.S Office of Personnel ManagementJuly 2005 Center for Federal Investigation Services

Agreement Number: OPM Use Only: OPM Codes: Case Number:

Agency use oniy (complete items 1 through 14 using instructions from the back)1. Subject’s Full Name 2. Date of BirthLast Name First Name Middle Name (at birth) Month Day Year

3. Place of Birth 4. SSNCity County State Country

5. Other Names Used and Dates When Used - —_____

Name From From Name From FromMonth Year Month Year Month Year Month Year

Name From From Name From FromMonth 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

1 0 0 3 V A 6 0 3600-1200 101-50813. Name and Title of Signature of Requesting Official Telephone Number Date

Requesting Official404-321-6111 X6306

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) 555-5555

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:

http://vaww.va.gov/PIVPROJECT/Training_Docs/Identity_Documentation_Criteria.pdf

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:

http://vaww.va.gov/PIVPROJECT/PIV_Badge_Offices.asp

(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:

http://vaww.va.gov/PIVPROJECT/Training_Docs/Identity_Documentation_Criteria.pdf

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) 728-7703

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): _________________________________________________________________

Employee Social Security No.: ___________________________________________________________

Part B – Requesting Office Data (completed by the Requesting office)

Facility: Atlanta VAMC

Address: 1670 Clairmont Road, Decatur, GA 30033

Contact Name: Dr. John Doe Contact Phone: (404) 555-5555

Contact Email: John.Doe@VA.gov Contact Fax: (404) 555-5555

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 Email: ____________________________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

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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 www.tms.va.gov to Create New User Record

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.

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Talent Management System

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, e-mail address, and legal name; proceed to Step 5. Step 4a If you are a foreign national, click the click here link. Step 4b If there is a security pop-up click Allow. Step 4c In the email pop-up add any additional information to assist the Admin like your name and contact information and click Send.

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Talent Management System

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. VA City: Decatur VA State: GA VA Location Code: ATG VA POC: Choose from list attached Email: Choose from list attached Phone 4047287703

Step 6 If you are required to take training on the Health Insurance Portability and Accountability Act (HIPPA), click the box.

Step 7 Click Submit.

Step 8 From the congratulations page, note your VA TMS USER ID for future use.

Step 9 Click Continue.

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Talent Management System

Task B. Complete Required Training

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. Step 3 Complete training per instructions.

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.

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Talent Management System

Program Coordinator/Director Name Specialty/Subspecialty E-Mail Address

Walid Nassif, MD, Psychiatry Addiction psychiatry walid.nassif@va.gov

David Fishman, MD, Chief, Anesthesiology Anesthesiology david.fishman@va.gov

Maziar Zafari, MD, CCU Director, Cardiology Cardiovascular disease maziar.zafari@va.gov

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

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Talent Management System

Mark Walsh, MD, Interim Chief, Plastic Surgery Plastic surgery mark.walsh@va.gov

Angel Jimenez, DPM, Program Director Podiatry Surgery angel.kimenez@va.gov

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