VA Form 0880A "Memorandum of Service Level Expectations for Part-Time Physician on Adjustable Work Hours"

What Is VA Form 0880A?

This is a legal form that was released by the U.S. Department of Veterans Affairs on December 1, 2006 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2006;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 0880A by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

ADVERTISEMENT
ADVERTISEMENT

Download VA Form 0880A "Memorandum of Service Level Expectations for Part-Time Physician on Adjustable Work Hours"

1483 times
Rate (4.8 / 5) 74 votes
MEMORANDUM OF SERVICE LEVEL EXPECTATIONS FOR
PART-TIME PHYSICIAN ON ADJUSTABLE WORK HOURS
PRIVACY ACT STATEMENT: The Department of Veterans Affairs (VA) is asking you to provide the information on this form under
the authority of Section 7405(a)(1)(a) of Title 38, United States Code in order for VA to determine the expected level of commitment and
estimate the amount of time a part-time physician is expected to dedicate to patient care, administrative, research, and educational
activities. The information you provide will become part of the "General Personnel Records (Title 38)-VA" (76VA05) Privacy Act
system of records. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use"
disclosure of the information for: civil or criminal law enforcement; litigation in which the United States is a party or has an interest;
Federal or State licensing boards; and personnel administration. Providing this information to VA is voluntary. However, if you do not
provide the information, VA will be unable to employ you as part-time physicians placed on adjustable work hours must complete and
sign a Memorandum of Service Level Expectations.
NAME OF VA FACILITY
FACILITY ADDRESS
FACILITY
STATION NO.
EMPLOYEE AGREEMENT/CERTIFICATION
1. Under regulations issued by the Secretary of Veterans Affairs, hereinafter referred to as the Secretary, I understand that I
am to provide to the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA)
hours of
service during the period beginning
; and ending
. Generally, these
hours are to be divided as follows:
% (patient care),
% (administration),
% (research), and
% (education). I understand I may terminate this memorandum at any time; that my pay and benefits will be
determined in accordance with regulations issued by the Secretary, and that this memorandum does not alter the applicability
of VHA regulations or procedures concerning the terms, conditions, or duration of my employment. It is further understood
that this memorandum does not constitute an employment contract.
2. This memorandum shall be effective upon approval by the Secretary (or designee) of the amount payable, provided I am
otherwise eligible, shall commence on the date prescribed in accordance with regulations.
3. If this memorandum expires or is terminated, the hours of service I have provided and salary and benefits I have received
during the term of this memorandum will be compared. If I have provided service for which I have not been compensated,
VHA will compensate me for such service in accordance with regulations issued by the Secretary or designee. If I have been
compensated for hours of service I have not provided, I understand I am to refund such excess compensation to VHA in
accordance with regulations issued by the Secretary or designee. It is further understood that any amount due on my behalf
will be considered to be a debt due to the United States that I am to pay in full as directed by VA.
4. I understand that this Memorandum of Service Level Expectations terminates when any of the following occur:
a. Separation from VHA employment for any reason.
b. Transfer to another VHA facility.
c. Acceptance of a position that does not qualify for adjustable work hours.
d. Completion of agreed period of service, or enactment of superseding law.
e. Execution of a superseding Memorandum of Service Level Expectations.
5. I acknowledge that VA Directive 5011 and VA Handbook 5011, part II, issued by the unit secretary (or designee) to
implement adjustable work hours, are incorporated into and made a part of this memorandum and I have read a copy.
6. I acknowledge that the unit secretary (or designee) may, pursuant to regulations, adjust the amount of the pay to which I
am entitled to reflect appropriately any change in my basic pay, special pay (if applicable), or position status (e.g., proportion
of part-time employment or change in level of responsibility).
SIGNATURE OF APPLYING PHYSICIAN
DATE SIGNED
APPROVAL SIGNATURE, UNIT SECRETARY OR DESIGNEE DATE SIGNED
APPROVAL SIGNATURE, FACILITY DIRECTOR OR DESIGNEE DATE SIGNED
0880a
VA Form
DEC 2006
MEMORANDUM OF SERVICE LEVEL EXPECTATIONS FOR
PART-TIME PHYSICIAN ON ADJUSTABLE WORK HOURS
PRIVACY ACT STATEMENT: The Department of Veterans Affairs (VA) is asking you to provide the information on this form under
the authority of Section 7405(a)(1)(a) of Title 38, United States Code in order for VA to determine the expected level of commitment and
estimate the amount of time a part-time physician is expected to dedicate to patient care, administrative, research, and educational
activities. The information you provide will become part of the "General Personnel Records (Title 38)-VA" (76VA05) Privacy Act
system of records. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use"
disclosure of the information for: civil or criminal law enforcement; litigation in which the United States is a party or has an interest;
Federal or State licensing boards; and personnel administration. Providing this information to VA is voluntary. However, if you do not
provide the information, VA will be unable to employ you as part-time physicians placed on adjustable work hours must complete and
sign a Memorandum of Service Level Expectations.
NAME OF VA FACILITY
FACILITY ADDRESS
FACILITY
STATION NO.
EMPLOYEE AGREEMENT/CERTIFICATION
1. Under regulations issued by the Secretary of Veterans Affairs, hereinafter referred to as the Secretary, I understand that I
am to provide to the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA)
hours of
service during the period beginning
; and ending
. Generally, these
hours are to be divided as follows:
% (patient care),
% (administration),
% (research), and
% (education). I understand I may terminate this memorandum at any time; that my pay and benefits will be
determined in accordance with regulations issued by the Secretary, and that this memorandum does not alter the applicability
of VHA regulations or procedures concerning the terms, conditions, or duration of my employment. It is further understood
that this memorandum does not constitute an employment contract.
2. This memorandum shall be effective upon approval by the Secretary (or designee) of the amount payable, provided I am
otherwise eligible, shall commence on the date prescribed in accordance with regulations.
3. If this memorandum expires or is terminated, the hours of service I have provided and salary and benefits I have received
during the term of this memorandum will be compared. If I have provided service for which I have not been compensated,
VHA will compensate me for such service in accordance with regulations issued by the Secretary or designee. If I have been
compensated for hours of service I have not provided, I understand I am to refund such excess compensation to VHA in
accordance with regulations issued by the Secretary or designee. It is further understood that any amount due on my behalf
will be considered to be a debt due to the United States that I am to pay in full as directed by VA.
4. I understand that this Memorandum of Service Level Expectations terminates when any of the following occur:
a. Separation from VHA employment for any reason.
b. Transfer to another VHA facility.
c. Acceptance of a position that does not qualify for adjustable work hours.
d. Completion of agreed period of service, or enactment of superseding law.
e. Execution of a superseding Memorandum of Service Level Expectations.
5. I acknowledge that VA Directive 5011 and VA Handbook 5011, part II, issued by the unit secretary (or designee) to
implement adjustable work hours, are incorporated into and made a part of this memorandum and I have read a copy.
6. I acknowledge that the unit secretary (or designee) may, pursuant to regulations, adjust the amount of the pay to which I
am entitled to reflect appropriately any change in my basic pay, special pay (if applicable), or position status (e.g., proportion
of part-time employment or change in level of responsibility).
SIGNATURE OF APPLYING PHYSICIAN
DATE SIGNED
APPROVAL SIGNATURE, UNIT SECRETARY OR DESIGNEE DATE SIGNED
APPROVAL SIGNATURE, FACILITY DIRECTOR OR DESIGNEE DATE SIGNED
0880a
VA Form
DEC 2006