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Number Title Issue Date Revision Date # Pages
10-0094a Medical Education Affiliation Agreement - School of Medicine (FILLABLE) 11/19/2004 7
10-0094b Medical Education Affiliation Agreement - Osteopathic Medicine (FILLABLE) 11/19/2004 7
10-0094c Medical Education Affiliation Agreement - Graduate Medical Education (FILLABLE) 11/19/2004 6
10-0094d Medical Education Affiliation Agreement - School of Dentistry (FILLABLE) 11/19/2004 6
10-0094e Medical Education Affiliation Agreement - VA Sponsor - Dentistry (FILLABLE) 11/19/2004 6
10-0094f Dental Education Affiliation Agreement (FILLABLE) 11/19/2004 5
10-0094g Associated Health Education Affiliation Agreement (FILLABLE) 11/19/2004 4
10-0094h Education Affiliation Agreement - Non-VA Health Care Facility (FILLABLE) 11/19/2004 4
10-0102 CAREER DEVELOPMENT APPLICATION - fillable 03/30/2006 2
10-0137 VA Advance Directive: Living Will & Durable Power of Attorney for Health Care 06/05/2003 12/2006 6
10-0137A Your Rights Regarding Advance Directives - fillable 01/08/2007 1
10-0137B WHAT YOU SHOULD KNOW ABOUT ADVANCE DIRECTIVES 01/08/2007 1
10-0143 Certification Regarding Drug-Free Workplace- fillable 11/24/2004 09/2006 2
10-0143a Statement of Assurance of Compliance with Sec. 504 of the Rehabilitation Act 11/24/2004 09/2006 1
10-0144 Certification Regarding Lobbying - fillable 11/24/2004 09/2006 1
10-0144a Statement of Assurance of Compliance with Equal Opportunity Laws- fillable 11/24/2004 07/2006 1
10-0361 Homeless Providers Grant and Per Diem Program 08/25/2004 1
10-0376a Credentials Transfer Brief - Fillable 09/08/2005 07/2005 2
10-0379 Ecclesiastical Endorsing Organization Verification/Reverification Info. - fill 12/29/2004 12/2005 3
10-0381 Civil Rights Discrimination Complaint - Fillable 11/04/2005 1
10-0388 Documents & Information Required for State Home Construction & Acquisition Grant 09/07/2005 03/2005 1
10-0388-1 Initial Application for State Home Construction & Acquisition 09/07/2005 03/2005 2
10-0388-10 Cert. of Compliance with Federal Requirements - State Home Construction Grant 09/07/2005 03/2005 1
10-0388-11 Memorandum of Agreement for a Grant to Construct or Acquire State Veterans Home 09/07/2005 03/2005 2
10-0388-12 Cert Re Debarment, Suspension, Ineligibility, Voluntary Exclusn-Lower Tier Tran 09/07/2005 03/2005 2
10-0388-13 Docs & Info Required for State Home Construction/Acquisition-Post Grant Requir's 09/07/2005 03/2005 1
10-0388-14 Checklist of Major Requirements for State Home Construction/Acquisition Grants 09/07/2005 2
10-0388-2 Cert. of Compliance w/ the Provisions of Davis-Bacon Act (40 USC 276a to 276a-7) 09/07/2005 03/2005 1
10-0388-3 State Home Construction Grant Program Space Program Analysis-Nursing Home & Dom 09/07/2005 03/2005 4
10-0388-4 State Home Construction Grant Program-Adult Day Health Care 09/07/2005 03/2005 4
10-0388-5 Add'l. Doc's. & Info. Required-State Home Construction /Acquisition Grants Appl. 09/07/2005 03/2005 4
10-0388-6 Certification of State Matching Funds to Qualify for Group 1 on Priority List 09/07/2005 03/2005 1
10-0388-7 Cert. Re Debarment, Suspension, Other ...-Primary Covered Transactions 09/07/2005 03/2005 2
10-0388-8 Cert. Re Drug-Free Workplace Requirments for Grantees Other than Individuals 09/07/2005 03/2005 2
10-0388-9 Certification Regarding Lobbying 09/07/2005 03/2005 1
10-0400 Request for VSO Access to CPRS (Computer Patient Record System) 08/06/2002 1
10-0400a CPRS Read-Only Rules for VSOs 08/06/2002 2
10-0408 VHA Fisher House Application (Fillable) 12/03/2004 09/2005 2
10-0415 VA Geriatrics and Extended Care (GEC) Referral - fillable 05/01/2006 5
10-0426 Meds By Mail Order Form CHAMPVA (Fillable) 03/31/2005 11/2008 2
10-0430 APPLICATION FOR ASSISTANCE FOR HIRING AND RETAINING NURSES AT STATE HOMES 09/01/2007 2
10-0436 Application for an Off-site Tissue Banking Waiver - Fillable 12/19/2005 5
10-0445 OCCUPATIONAL AND ENVIRONMENTAL EXPOSURE HISTORY - FILLABLE 11/30/2006 3
10-0459 Credentialing Release of Information Authorization 01/01/2008 1
10-0462 Political Acrivities Fact Sheet and Certification 05/05/2008 09/2008 1
10-1010EZ Application for Health Care Benefits 10-10EZ 08/06/2004 7/2008 5
10-1023 Information Regarding Possible Claim Against Third Party fillable Stock #F01399 04/02/2004 2
10-10d Application for CHAMPVA Benefits- Fillable 09/17/2004 06/2005 3
10-10EC Application For Extended Care Services 10/23/2003 05/2005 5
10-10EZ Application for Health Benefits 08/06/2004 7/2008 5
 
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