Yes
No
Used for assigning records entered by admin for appointment expiration tracking only.
Use this form to initiate an Intergovernmental Personnel Act (IPA) detail or Without Compensation (WOC) appointment request with the Madison VA Research Service. Once submitted, p lease allow up to five business days for review. You will receive an email notification with t he review outcome and i nstructions for next steps.
First name: Last name: Preferred email address: Request date:
First name of person submitting this request.
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Last name of person submitting this request.
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Preferred email of the person submitting this request.
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Today Y-M-D *enter the date that this request is being submitted.
IPA Start Date: IPA End Date:
IPA Start Date: IPA End Date:
WOC Start Date: WOC End Date:
WOC Start Date: WOC End Date:
IPA WOC
Is the IPA request for a paid or zero-dollar appointment?
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Paid appointment Zero-dollar appointment
Select paid appointment if VA funding will be used to support the candidate's salary.
Request type:
Select "New " if the candidate does not have a valid VA appointment (i.e., new employee) or does not currently hold the specific appointment type you are requesting (e.g., WOC request for a candidate transitioning off an existing IPA).
Select "Extension " if the candidate's existing appointment is expiring and you want to renew it.
Select "Modification " if the candidate has an existing IPA appointment and the total budget within the existing appointment timeframe is being changed.
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New Extension Modification (IPA Only)
Select the most applicable position title for the requested appointment
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Biomedical Engineer Biostatistician Co-Investigator Data Analyst Data Coordinator Data Scientist Lab Assistant Lab Coordinator Lab Technician Outreach Specialist Principal Investigator Research Coordinator Research Dietician Research Nurse Research Nurse Practitioner Research Program Manager Research Project Manager Research Project Supervisor Research Scientist Research Specialist Veterinary Technician Other Undergraduate Researcher
Select the most applicable position title for the requested appointment
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1531 Statistical Assistant 1529 Mathematical Statistician 1530 Statistician 1550 Computer Scientist 0671 Health Systems Specialist 0640 Health Technician 0601 Health Science Specialist 0101 Social Science Analyst/Social Science Program Coordinator 0404 Biological Laboratory Technician 5048 Animal Caretaker 0401 Research Biologist/Microbiologist/Neurologist 0601 Health Scientist 0101 Qualitative Scientist 0671 Health Systems Specialist 1515 Operations Research Analyst 0610 Research Nurse 0602 Research Physician 0180 Research Psychologist 301 Program Manager
Position description
Template
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Primary work location Address: Building number:
Room number:
Position duties 1. Will the work to be performed directly involve intervention or interaction with human research subjects? 2. Will the work to be performed involve accessing, using, or storing human research data?
3. Will the work performed support animal research? 4. Will the work be performed in VA owned or leased space?
Justify why a ______ is needed for work performed outside of the VA.
Will the work to be performed directly involve intervention or interaction with human research subjects?
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Yes No
Will the work to be performed involve accessing, using, or storing human research data?
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Yes No
Will the work performed support animal research?
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Yes No
Will the work be performed in VA owned or leased space?
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Yes No
Please provide justification for why a WOC or IPA is needed for work performed outside of the VA.
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Requested IPA appointment start date
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Today Y-M-D *The earliest possible start date for a new IPA appointment is 45 days from when the request is submitted for review.
Estimated IPA max end date
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Requested IPA appointment end date
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Today Y-M-D *The appointment end date must not extend beyond (1) two years of the appointment start date OR (2) the VA award end date.
Requested start date for IPA appointment renewal or modification.
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Today Y-M-D
Estimated max end date for IPA renewal
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Requested end date for IPA appointment renewal or modification
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Today Y-M-D *The appointment end date must not extend beyond (1) two years of the appointment start date OR (2) the VA award end date.
Upload IPA Agreement (OF-69) form:
Instructions for IPA Agreement (OF-69) form:
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Upload IPA Eligibility Letter:
Download Template Fill in template Obtain signature from your UW-Madison HR Dept. Upload for review
Instructions for IPA Eligibility Letter:
Download Template Fill in template Obtain signature from your UW-Madison HR Dept. Upload for review *
*The purpose of this letter is to verify that the candidate will be employed at the lending agency for at least 90 days prior to the IPA appointment start date.
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Requested WOC appointment start date
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Today Y-M-D *The earliest possible start date for a new WOC appointment is 30 days from when the request is submitted for review.
Estimated WOC max end date
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Requested WOC appointment end date
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Today Y-M-D *The requested appointment end date must be within 4 years or less of the requested start date.
Expiration date for current appointment.
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Today Y-M-D
Requested start date for WOC appointment renewal
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Today Y-M-D *This date should be identical to the expiration date for the current appointment.
Estimated max end date for WOC renewal
View equation
Requested end date for WOC appointment renewal
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Today Y-M-D
Please enter a justification for requesting a WOC appointment lasting less than 1 year.
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*Requests for new WOC appointments lasting < 1 year are discouraged and subject to review. Approvals will be considered on a case by case basis.
First name: Last name: Preferred email address: Phone number: Current home address: US citizenship status: Copy of most recent Resume/CV: Healthcare professional status:
Upload License/Certification
Preferred alternative VA onboarding location:
First name of the appointment candidate
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Last name of the appointment candidate
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Preferred email address of the appointment candidate
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Copy of most recent Resume/CV:
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Is the candidate a healthcare professional (e.g., RN, MD, NP, LPN, RD)?
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Yes, the candidate is a healthcare professional No, the candidate is not a healthcare professional
Healthcare professional License/Certification
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Candidate can travel to Madison VA for onboarding Candidate needs to rely on another VA for onboarding
In what zip code is the candidate located?
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Disclaimer Please note that appointment requests for candidates who cannot travel to the Madison VA are contingent on the ability of another VA Hospital or Clinic to provide support with fingerprinting, background check, and an employee health examination.
What is the candidate's US citizenship status?
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US Citizen Non-US Citizen, Green Card Non-US Citizen, F-1 Visa Non-US Citizen, H-1B Visa Non-US Citizen, H-4 Visa Non-US Citizen, J-1 Visa Non-US Citizen, J-2 Visa Non-US Citizen, O-1 Visa
*STOP HERE*
Unfortunately we can not process this request because the VA is not authorized to grant WOC appointments to non US citizens with the following Visa types:
Info Sheet
Disclaimer : After submitting this request, your candidate will be asked to provide an I-20 form with evidence of completing at least 1 year of curricular practical training (CPT) or optional practical training (OPT). This is a requirement for providing a WOC appointment to non-US citizens with F-1 visa status.
CPT & OPT Info
Disclaimer : Non-US citizens with F-1 visa status typically require at least 1 year of curricular practical training (CPT) or optional practical training (OPT). However, some research labs are eligible for exemption from this requirement. Do you wish to apply for exemption?
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Yes
No
Upload a copy of your CPT/OPT exemption letter:
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Select your preferred option. WOC appointment requests for non-US citizens require one of the following:
University attestation letter (university students only) USA Jobs Posting (university students & non-students) Info Sheet
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University attestation letter USA Jobs Posting
Upload your university attestation letter here.
Template
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Disclaimer : You selected the option of posting the position on USA Jobs. Please review the following information and click the acknowledgement statement before moving forward with this request.
Appointment processing time:
The selected option will increase the minimum estimated processing time for this appointment from 30 to 70 days. Before this request can be submitted:
A detailed position description is needed A detailed description of the laboratory work environment is needed Before onboarding paperwork can be processed by HR VA:
A job opportunity accouncement (JOA) must be posted to USA Jobs for two calendar weeks to document that no US citizens were available for the appointment. Posting the JOA does not guarantee that the candidate will be offered the position. I have read the disclaimer and would like to continue with my request.
Name: Preferred email: Primary academic department/division:
Select the PI that the candidate will be working with.
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Adam Gepner Adam Konopka Adnan Said Cathy Gallagher Christopher Crnich Christopher Fletcher Cynthia Carlsson Corrine Voils Courtney Balentine Dane Cook David Murray David Harris David Kosoff David Andes Dawn Davis Dudley Lamming Evie Carchman Hao Chang Jeremy Kratz Jessica Cook Jessica Schuster John Swietlik Joshua Mezrich Julie Keating Justine Bruce Luigi Puglielli Luke Funk Manish Patankar Mark Albertini Mary Wyman Matt Merrins Michelle Kimple Mihaela Teodorescu Miriam Shelef Mohun Ramratnam Nasia Safdar Nicole Rogus-Pulia Nihal Ahmad Pallavi Tiwari Pamela Crary Prakash Balasubramanian Raghu Vemuganti Rozalyn Anderson Ruben Alexanian Samuel Poore Sara Best Sujani Kakumanu Timothy Juergens Timothy McCulloch Vijay Setaluri Other Meghan Brennan Cristina Sanger Kyle Richards Thor Ringler David Foley Hilary Faust Matthew Churpek
*Begin typing the PI's name to auto-populate this field.
Enter the first and last name of the PI that the candidate will be working with.
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PI's primary school/college
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School of Education
School of Medicine and Public Health
School of Pharmacy
School of Veterinary Medicine
Other
PI's primary academic department/division
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534220 Allergy/Immunology (DOM) 531200 Biostatistics & Medical Informatics 531240 Biostatistics & Medical Informatics 534225 Cardiology (DOM) 534200 Department of Medicine (DOM) 534252 Department of Medicine (DOM) 534300 Dermatology 534245 Endocrinology (DOM) 539742 General Surgery 534255 Geriatrics/DOM 534260 Hematology/Oncology (DOM) 534265 Infectious Disease (DOM) 176000 Kinesiology 535700 Neurological Surgery 535100 Neurology 549000 Nursing 532840 OB/GYN 539770 Otolaryngology/Surgery 561000 Pharmacy 568000 Pharmacy 534285 Pulmonary Medicine (DOM) 539707 Surgery 539730 Surgery 533400 UW Comprehensive Cancer Center 533466 UW Comprehensive Cancer Center 872100 Vet Med 539722 WI Surgical Outcomes Research Program/Surgery Other
First name: Last name: Preferred email: Phone number: Is there a secondary administrator who should be associated with this request?
First name: Last name: Preferred email: Phone number:
First name of the PI's administrator
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Last name of the PI's administrator
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Preferred email for PI's administrator
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Phone number for PI's adminstrator
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Is there a secondary administrator who should be associated with this request?
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Yes No
First name of the PI's secondary administrator
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Last name of the PI's secondary administrator
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Preferred email for PI's secondary administrator
Phone number for PI's secondary administrator
Title: Funding source: Funding administrator:
VA Program Office VA Research Appropriation VA Special Purpose Funding VA QUERI NIH Non Profit Private Other Unfunded
Project funding source (Other)
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N/A VA Research VA Medical Care VA NPC University Affiliate Other
Enter today's date before submitting:
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Today Y-M-D
Please select the sex that was recorded for you at birth.
*This information is needed for Selected Service documentation purposes.
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Male Female
Do you have a social security number?
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Yes
No
Disclaimer:
Working at the VA requires a social security number. If you don't have a social security number, apply for one - Here
Upload a copy of your VISA
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Upload a copy of your passport
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Upload a copy of your I-20 form
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Upload a copy of your I-20 form
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Helpful hints:
Fill out everything above "REASON FOR FINGERPRINTING"
Helpful hints:
If you have no middle name please write "NO MIDDLE NAME" on line 1 Sign BOTH lines 17a and 17b applicants signature AND appointee's signature)
Helpful hints:
Fill out section 1, and Sign/date
Helpful hints:
Check "Other" and indicate "Researcher" Fill out remaining sections Sign/date the last page
Helpful hints:
Please check appropriate box Sign/date
Helpful hints:
Check NEW on the top if you have not used this form before. Both you and your PI need to sign page 6 Enter the dates you completed the trainings on page 7
COVID vaccine card upload:
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*Please upload as .PDF or .JPG format
*Sign your WOC appointment letter and upload here.
Enter today's date before submitting:
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Today Y-M-D
Enter today's date before submitting:
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Today Y-M-D
Full name (as shown on driver's license or passport)
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More than 6 months or 180 days in a year Less than 6 months or 180 days in a year
Enter the most applicable position title
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Today Y-M-D
Today Y-M-D
VA award budget verification: Upload your most recent VA project budget briefing sheet to verify sufficient funding to support your new IPA request.
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If you have not received a VA budget briefing within the past month, contact John Hahn to set up a meeting for a budget consultation.
Will the work to be performed directly involve intervention or interaction with human research subjects?
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Yes
No
Please briefly describe how the candidate will be interacting with VA patients.
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Add any information that you think would be helpful for the budget reviewer to know.
Which VA research activities will the candidate perform?
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Human Studies Human Studies + Lab activities Lab Activities Only Animal Studies
*This is relevant for accurate assignment of VA research training requirements.
Instructions for IPA Budget form:
Template
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Is the candidate a healthcare professional (e.g., RN, MD, NP, LPN, RD)?
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Yes
No
Upload a position description for the USAJobs posting.
Template
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Is the request for a candidate who cannot travel to the Madison VA for onboarding appointments?
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Yes
No
Submit
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