VA Providence Healthcare System
Sensory and Physical Rehabilitation Service
Educational - Sensory & Physical Rehabilitation Service
Physical Therapy (PT), Occupational Therapy (OT), Audiology (AUD),
Clinical Placement Checklist
PT: Wendy Cardoza 401-273-7100 ext. 2613, Wendy.Cardoza@va.gov
OT: Erinn Raimondi 401-273-7100 ext. 3234, Erinn.Raimondi@va.gov
AUD: Andrew Smith 401-273-7100 ext. 1521, Andrew.Smith6@va.gov
HSS: Laurie Diefenbach 401-273-7100 ext. 2202, Laurie.Diefenbach@va.gov
Listed below are the required documents you must complete and return to your discipline specific clinical coordinator and Laurie Diefenbach no later than 6 weeks prior to your clinical experience. Please closely follow the directions. We recommend you print this page to assist you in the student clinical placement application process.
Step 1: Application
Student completes all of the below bulleted forms in link-EVEN the ones that are titled "optional". Please follow up with your discipline specific clinical coordinator and Laurie Diefenbach within two business days of application to ensure information was received.
- VHA-1-2850d-fill- Complete sections I - III, skip section IV. Complete sections V - VIIII as applicable, section X answer NO TO ALL and sign on the bottom of page 3 & page 4.
- Form 306, Declaration of Federal Employment
- Fingerprint Form and Standard Form-85, Authorization for Release of Information. NOTE: IF YOU WERE NOT U.S. BORN, please include a photocopy of a citizenship document to show you are legal to be in the U.S., i.e. naturalization certification, resident alien card, passport, etc. The photocopy must be legible.
- i9 (Employment Eligibility Verification Form)
- Note: Once Human Resources (HR) processes your packet students will be contacted by Laurie Diefenbach to make appointments for fingerprinting. (Directions to VA Medical Center & Eagle Square). You will need two IDs with you on that day from the attached list.
Please ensure all forms are signed and dated prior to mailing.
Forms Do Not need to be notarized.
75 Eagle St
Providence, RI 02908
Step 2: Educational Training
All students must log into TMS 2.0 to complete the on-line courses. The courses you are required to take should be on your TMS “To do” list. Audiology and PT paid trainee students must complete Mandatory Training for Trainees- Refresher (course# 3192008) and Privacy and HIPPA (course#10203). OT and Audiology WOC students must complete VA Privacy and Information Security Awareness and Rules of Behavior (course#10176) and Privacy and HIPPA (course#10203). Please submit the certificates of completion with your application.
Step 3: Basic Life Support Cerification
Student must have an active and valid BLS card throughout the entirety of the fieldwork placement which must be provided to the VA prior to starting. The VA only accepts certification from either the American Heart Association (AHA) or the Military Training Network.
Step 4: Vehicle Information
All students require a paper parking pass to park at our Outpatient clinics. Please provide the make, model, color, year and license plate (including state)
If you have any questions or concerns about the process or the forms, please contact discipline specific clinical coordinator or Laurie Diefenbach via email as listed above.
75 Eagle Street
- 401-273-7100 Ext. 3227
Hours of Operation
- M-F 8:00 a.m. - 4:30 p.m.