79VA19

Categories of individuals covered by the system:
The records include information concerning current and former employees, applicants for employment, trainees, contractors, sub- contractors, contract personnel, students, providers and consultants, patients and members of their immediate family, volunteers, maintenance personnel, as well as individuals working collaboratively with the VA.

Categories of records in the system:

The records may include information related to:

1. Workload such as orders entered, verified, and edited (e.g., engineering work orders, doctors' orders for patient care including nursing care, the scheduling and delivery of medications, consultations, radiology, laboratory and other diagnostic and therapeutic examinations); results entered; items checked out and items in use (e.g., library books, keys, x-rays, patient medical records, equipment, supplies, reference materials); work plans entered and the subsequent tracking (e.g., construction projects, engineering work orders and equipment maintenance and repairs assigned to employees and status, duty schedules, work assignments, work requirements); reports of contact with individuals or groups; employees (including volunteers) work performance information (e.g., duties and responsibilities assigned and completed, amount of supplies used, time used, quantity and quality of output, productivity reports, schedules of patients assigned and treatment to be provided);
2. Administrative procedures, duties, and assignments of certain personnel;
3. Computer access authorizations, computer applications available and used, information access attempts, frequency and time of use; identification of the person responsible for, currently assigned, or otherwise engaged in various categories of patient care or support of health care delivery; vehicle registration (motor vehicles and bicycles) and parking space assignments; community and special project participants/attendees (e.g., sports events, concerts, National Wheelchair Games); employee work-related accidents. The record may include identifying information (e.g., name, date of birth, age, sex, social security number, taxpayer identification number); address information (e.g., home and/or mailing address, home telephone number, emergency contact information such as name, address, telephone number, and relationship); information related to training (e.g., security, safety, in-service), education and continuing education (e.g., name and address of schools and dates of attendance, courses attended and scheduled to attend, grades, type of degree, certificate, etc.); information related to military service and status; qualifications for employment (e.g., license, degree, registration or certification, experience); vehicle information (e.g., type make, model, license, and registration number); evaluation of clinical and/or technical skills; services or products purchased (e.g., vendor name and address, details about and/ or evaluation of service or product, price, fee, cost, dates purchased and delivered, employee workload, and productivity data); employee work-related injuries (cause, severity, type of injury, body part affected);
4. Financial information, such as service line and clinic budgets, projected and actual costs;
5. Supply information, such as services, materials and equipment ordered;
6. Abstract information (e.g., data warehouses, environmental and epidemiological registries, etc.) is maintained in auxiliary paper and automated records;
7. Electronic messages; and
8. The social security number and universal personal identification number of health care providers.

Authority for maintenance of the system:
Title 38, United States Code, section 7301(a).

Purpose(s):
The records and information may be used for statistical analysis to produce various management, workload tracking and follow-up reports; to track and evaluate the ordering and delivery of equipment, services and patient care; the planning, distribution and utilization of resources; the possession and/or use of equipment or supplies; the performance of vendors, equipment, and employees; and to provide clinical and administrative support to patient medical care. The data may be used for research purposes. The data may be used also for such purposes as assisting in the scheduling of tours of duties and job assignments of employees; the scheduling of patient treatment services, including nursing care, clinic appointments, surgery, diagnostic and therapeutic procedures; the repair and maintenance of equipment and for follow-up to determine that the actions were accomplished and to evaluate the results; the registration of vehicles and the assignment and utilization of parking spaces; to plan, schedule, and maintain rosters of patients, employees and others attending or participating in sports, recreational or other events (e.g., National Wheelchair Games, concerts, picnics); for audits, reviews, and investigations conducted by staff of the health care facility, the Network Directors Office, VA Central Office, and the VA Office of Inspector General (OIG); for quality assurance audits, reviews, investigations and inspections; for law enforcement investigations; and for personnel management, evaluation and employee ratings, and performance evaluations.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses:
To the extent that records contained in the system include information protected by 45 CFR parts 160 and 164, i.e., individually-identifiable health information, and 38 U.S.C. 7332, i.e., medical treatment information related to drug abuse, alcoholism or alcohol abuse, sickle cell anemia or infection with the human immunodeficiency virus, that information cannot be disclosed under a routine use unless there is also specific statutory authority in 38 U.S.C. 7332 and regulatory authority in 45 CFR parts 160 and 164 permitting disclosure.

1. VA may disclose on its own initiative any information in this system, except the names and home addresses of veterans and their dependents, which is relevant to a suspected or reasonably imminent violation of law, whether civil, criminal or regulatory in nature and whether arising by general or program statute or by regulation, rule or order issued pursuant thereto, to a Federal, state, local, tribal, or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. On its own initiative, VA may also disclose the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.
2. Disclosure may be made to an agency in the executive, legislative, or judicial branch, or the District of Columbia government in response to its request, in connection with the hiring of an employee, the issuance of a security clearance, the conducting of a security or suitability investigation of an individual, the letting of a contract, the issuance of a license, grant, or other benefits by the requesting agency, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is relevant and necessary to the requesting agency's decision.
3. Disclosure may be made to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual.
4. Disclosure may be made to the National Archives and Records Administration (NARA) in records management inspections conducted under authority of 44 U.S.C.
5. Disclosure may be made to the Department of Justice and United States attorneys in defense or prosecution of litigation involving the United States, and to Federal agencies upon their request in connection with review of administrative tort claims filed under the Federal Tort Claims Act, 28 U.S.C.
6. Hiring, performance, or other personnel-related information may be disclosed to any facility with which there is or there is proposed to be an affiliation, sharing agreement, contract, or similar arrangement for purposes of establishing, maintaining, or expanding any such relationship.
7. Disclosure may be made to inform a Federal agency, licensing boards or the appropriate non-government entities about the health care practices of a terminated, resigned or retired health care employee whose professional health care activity so significantly failed to conform to generally accepted standards of professional medical practice as to raise reasonable concern for the health and safety of patients receiving medical care in the private sector or from another Federal agency. These records may also be disclosed as part of an ongoing computer matching program to accomplish these purposes.
8. For program review purposes, and the seeking of accreditation and/or certification, disclosure may be made to survey teams of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), College of American Pathologists, American Association of Blood Banks, and similar national accreditation agencies or boards with whom VA has a contract or agreement to conduct such reviews but only to the extent that the information is necessary and relevant to the review.
9. Disclosure may be made to a state or local government entity or national certifying body which has the authority to make decisions concerning the issuance, retention or revocation of licenses, certifications or registrations required to practice a health care profession, when requested in writing by an investigator or supervisory official of the licensing entity or national certifying body for the purpose of making a decision concerning the issuance, retention or revocation of the license, certification or registration of a named health care professional.
10. Disclosure may be made to officials of labor organizations recognized under 5 U.S.C. chapter 71 when relevant and necessary to their duties of exclusive representation concerning personnel policies, practices, and matters affecting working conditions.
11. Disclosure may be made to the representative of an employee, including all notices, determinations, decisions, or other written communications issued to the employee in connection with an examination ordered by VA under medical evaluation (formerly fitness- for-duty) examination procedures or Department-filed disability retirement procedures.
12. Disclosure may be made to officials of the Merit Systems Protection Board, and the Office of the Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of rules and regulations, investigation of alleged or possible prohibited personnel practices, and such other functions, promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.
13. Disclosure may be made to the Equal Employment Opportunity Commission when requested in connection with investigations of alleged or possible discrimination practices, examination of Federal affirmative employment programs, compliance with the Uniform Guidelines of Employee Selection Procedures, or other functions vested in the Commission by the President's Reorganization Plan No. 1 of 1978.
14. Disclosure may be made to the Federal Labor Relations Authority, including its General Counsel, when requested in connection with investigation and resolution of allegations of unfair labor practices, in connection with the resolution of exceptions to arbitrator awards when a question of material fact is raised and matters before the Federal Service Impasses Panel.
15. Disclosure may be made in consideration and selection of employees for incentive awards and other honors and to publicize those granted. This may include disclosure to other public and private organizations, including news media, which grant or publicize employee awards or honors.
16. Disclosure may be made to consider employees for recognition through administrative and quality step increases and to publicize those granted. This may include disclosure to other public and private organizations, including news media, which grant or publicize employee recognition.
17. Identifying information such as name, address, social security number and other information as is reasonably necessary to identify such individual, may be disclosed to the National Practitioner Data Bank at the time of hiring and/or clinical privileging/re-privileging of health care practitioners and at other times as deemed necessary by VA in order for VA to obtain information relevant to a Department decision concerning the hiring, privileging/ re-privileging, retention or termination of the applicant or employee.
18. Relevant information may be disclosed to the National Practitioner Data Bank and/or State Licensing Board in the state(s) in which a practitioner is licensed, in which the VA facility is located, and/or in which an act or omission occurred upon which a medical malpractice claim was based when VA reports information concerning: (1) Any payment for the benefit of a physician, dentist, or other licensed health care practitioner which was made as the result of a settlement or judgment of a claim of medical malpractice if an appropriate determination is made in accordance with agency policy that payment was related to substandard care, professional incompetence or professional misconduct on the part of the individual; (2) a final decision which relates to possible incompetence or improper professional conduct that adversely affects the clinical privileges of a physician or dentist for a period longer than 30 days; or, (3) the acceptance of the surrender of clinical privileges or any restriction of such privileges by a physician or dentist either while under investigation by the health care entity relating to possible incompetence or improper professional conduct, or in return for not conducting such an investigation or proceeding. These records may also be disclosed as part of a computer matching program to accomplish these purposes.
19. Disclosure of medical record data, excluding name and address, unless name and address is furnished by the requester, may be made to epidemiological and other research facilities for research purposes determined to be necessary and proper, and approved by the Under Secretary for Health.
20. Disclosure of name(s) and address(es) of present or former personnel of the Armed Services, and/or their dependents, may be made to: (a) a Federal department or agency, at the written request of the head or designee of that agency; or (b) directly to a contractor or subcontractor of a Federal department or agency, for the purpose of conducting Federal research necessary to accomplish a statutory purpose of an agency. When disclosure of this information is made directly to a contractor, VA may impose applicable conditions on the department, agency, and/or contractor to ensure the appropriateness of the disclosure to the contractor.
21. The social security number, universal personal identification number and other identifying information of a health care provider may be disclosed to a third party where the third party requires the agency to provide that information before it will pay for medical care provided by VA.
22. Relevant information may be disclosed to individuals, organizations, private or public agencies, etc., with whom VA has a contract or agreement to perform such services as VA may deem practical for the purposes of laws administered by VA, in order for the contractor and/or subcontractor to perform the services of the contract or agreement.
23. Disclosure of relevant health care information may be made to individuals or organizations (private or public) with whom VA has a contract or sharing agreement for the provision of health care, administrative or financial services.

Policies and practices for storing, retrieving, accessing, retaining, and disposing of records in the system:

Storage:
Records are maintained on paper, microfilm, magnetic tape, disk, or laser optical media. In most cases, copies of back-up computer files are maintained at off-site locations.

Retrievability:
Records are retrieved by name, social security number or other assigned identifiers of the individuals on whom they are maintained.

Safeguards:

1. Access to VA working and storage areas is restricted to VA employees on a ``need-to-know'' basis. Strict control measures are enforced to ensure that disclosure to these individuals is also based on this same principle. Generally, VA file areas are locked after normal duty hours and the facilities are protected from outside access by the Federal Protective Service or other security personnel.
2. Access to computer rooms at health care facilities is generally limited by appropriate locking devices and restricted to authorized VA employees and vendor personnel. Automated Data Processing (ADP) peripheral devices are placed in secure areas (areas that are locked or have limited access) or are otherwise protected. Information in VistA may be accessed by authorized VA employees. Access to file information is controlled at two levels. The systems recognize authorized employees by series of individually unique passwords/codes as a part of each data message, and the employees are limited to only that information in the file which is needed in the performance of their official duties. Information that is downloaded from VistA and maintained on personal computers is afforded similar storage and access protections as the data that is maintained in the original files. Access to information stored on automated storage media at other VA locations is controlled by individually unique passwords/codes. Access by remote data users such as Veteran Outreach Centers, Veteran Service Officers (VSO) with power of attorney to assist with claim processing, Veteran Benefits Administration (VBA) Regional Office staff for benefit determination and processing purposes, OIG staff conducting official audits, investigations or inspections at the health care facility, or an OIG office location remote from the health care facility and other authorized individuals is controlled in the same manner.
3. Information downloaded from VistA and maintained by the OIG headquarters and Field Offices on automated storage media is secured in storage areas for facilities to which only OIG staff have access. Paper documents are similarly secured. Access to paper documents and information on automated storage media is limited to OIG employees who have a need for the information in the performance of their official duties. Access to information stored on automated storage media is controlled by individually unique passwords/codes.

Retention and disposal:
Paper records and information stored on electronic storage media are maintained and disposed of in accordance with records disposition authority approved by the Archivist of the United States.

System manager(s) and address:
The official responsible for policies and procedures is the Director, Health Systems Design and Development (192), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420. The local official responsible for maintaining the system is the Director of the facility where the individual is or was associated.

Notification procedure:
Individuals who wish to determine whether this system of records contains information about them should contact the VA facility location at which they are or were employed or made or have contact. Inquiries should include the person's full name, social security number, dates of employment, date(s) of contact, and return address.

RECORD ACCESS PROCEDURE:
Individuals seeking information regarding access to and contesting of records in this system may write, call or visit the VA facility location where they are or were employed or made contact.

Contesting record procedures:
(See Record Access Procedures, above.)

Record source categories:
Information in this system of records is provided by the individual, supervisors, other employees, personnel records, or obtained from their interaction with the system.

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