Providence VA Medical Center, Rhode Island
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
Listed below are all the required forms and processes you must review and/or fill out and return your discipline specific clinical coordinator no later than 6 weeks prior to your clinical experience. Please closely follow the directions. If you have any questions or concerns about the process or the forms, please contact your discipline specific clinical coordinator as listed above. We recommend you print this page to assist you in the student clinical placement application process.
Step 1: Student completes all of the below bulleted forms in link-EVEN the ones that are titled "optional" Forms must be received by your discipline specific clinical coordinator six weeks prior to the first day of clinical rotation. Please follow up with your discipline specific clinical coordinator 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: Students will be contacted by your discipline specific clinical coordinator to make appointments to process in through Human Resources (HR) for fingerprinting and photo for ID badges at least six weeks prior to the first day of clinical rotation. 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
- All students must complete the on-line course 'Mandatory Training for Trainees' (Refresher, HIPPA etc.) - print the certificate of completion, and submit with your application.
- (The embedded attachment has direction -VA Mandatory Training for Trainees)
- When finished, print the certificate and forward it to your specific discipline clinical coordinator.
Certificate of Completion from Mandatory Training website must accompany application forms.
Step 3: Students on independent clinical or leadership rotations:
You will be contacted to schedule an appointment for fingerprinting and photo for ID Badge after applications forms are received.
(Directions to VA Medical Center & Eagle Square)
* 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.
If you have any questions or concerns about the process or the forms, please contact discipline specific clinical coordinator as listed above.
75 Eagle Street
- 401-273-7100 Ext. 3227
Hours of Operation
- M-F 8:00 a.m. - 4:30 p.m.