VA Form 10-10169: Volunteer Consent Form Guide

VA Form 10-10169: Volunteer Consent Form Guide – If you are a current Veterans Health Administration (VHA) employee or trainee who has been asked to participate in MRI pulse sequence testing for quality improvement, you will likely need to complete VA Form 10-10169, the official Volunteer Consent Form. This form documents informed consent for a specific internal quality improvement activity conducted by VA Radiology Service.

Download the official form here:
Download VA Form 10-10169 Volunteer Consent Form (PDF)

The form is three pages and was last revised in June 2019. It remains the current version available on the VA website.

What Is VA Form 10-10169?

VA Form 10-10169 is titled Volunteer Consent Form – Participation in Testing of MRI Pulse Sequences Needed for MRI Optimization as part of Radiology Service Quality Improvement Program.

It is used when VHA staff volunteer to undergo Magnetic Resonance Imaging (MRI) scans. The goal is to help Radiology Service test, optimize, and improve MRI equipment and imaging protocols that will ultimately be used for veteran patients. The images and data collected support internal quality improvement only.

Important distinction: This is not a general volunteer form for the VA Voluntary Service program. It is also not a research consent form used for human subjects research studies.

Who Can Use VA Form 10-10169? (Eligibility)

The form contains a clear eligibility statement:

“Eligible volunteers are limited to current VHA employees, including VHA trainees (interns, residents, etc.). This is not a volunteer activity for volunteers in VA Voluntary Service, who serve on a Without Compensation (WOC) basis.”

Only current VHA employees and trainees may participate in this specific MRI quality improvement activity. Regular VA volunteers (WOC) use different processes.

Participation is completely voluntary. Your decision to participate or decline will have no effect on your employment status, duties, or performance evaluations.

Purpose of the Form

The primary purpose is to ensure that VHA employees who volunteer for MRI pulse sequence optimization:

  • Understand the nature of the activity (MRI scanning for equipment and protocol testing, not personal medical diagnosis or treatment).
  • Acknowledge MRI safety requirements and screening.
  • Understand how images and data will be used and stored (solely for quality improvement, in accordance with VHA Record Control Schedule RCS 10-1).
  • Accept responsibility for any incidental findings.
  • Provide documented consent before any scanning begins.

The form explicitly states that this activity does not constitute human subjects research because it is conducted for internal quality improvement purposes.

How to Fill Out VA Form 10-10169? (Step-by-Step)

VA Form 10-10169 is primarily an informed consent document rather than a complex multi-field application. Here’s how to complete it properly:

  1. Read the entire form carefully before signing. It contains important explanations about the purpose, risks, benefits, and your rights.
  2. Review the separate MRI Screening form provided by Radiology Service. You must be cleared for MRI safety.
  3. Complete Section VI – Certification by signing and dating as the volunteer.
  4. Print your full name clearly.
  5. Have the VA Official (usually Radiology Service staff obtaining your permission) sign, date, and provide their title.
  6. Keep a copy for your personal records. The original is retained by VA according to records policy (generally destroy after 7 years at the end of the calendar year in which testing occurred).

The form must be completed prior to any volunteer participation in the MRI testing activity.

Key Sections Explained

I. Purpose and Conduct of Testing
Explains that you are volunteering for MRI scans to optimize pulse sequences and imaging protocols for future patient use. MRI is described as generally safe and non-invasive when standard safety screening is followed. No ionizing radiation is involved.

II. Terms of Participation
You voluntarily consent to participate. You agree to follow all MRI safety procedures. You acknowledge that Radiology staff are not providing diagnosis or treatment, and no physician-patient relationship is created. You understand the time commitment and that you may participate on your own time or approved administrative leave.

III. Liability
Any liability of the United States is governed by the Federal Tort Claims Act.

IV. Revocation of Consent
You may revoke consent at any time, for any reason, even after scanning has started. Withdrawal will not affect your employment.

V. Incidental Findings
This is one of the most important sections. MRI images taken for quality improvement purposes are not a full diagnostic exam.

  • Insignificant findings may or may not be noted.
  • Significant incidental findings will be briefly noted on the form.
  • You are responsible for deciding whether to seek clinical follow-up and for arranging it at your own expense through your personal healthcare provider (not through VA Occupational Health Services).

VI. Certification
Your signature confirms you have read, understood, and agree to the terms.

Important Considerations

  • Safety first: MRI involves powerful magnetic fields. Strict screening for metal implants, devices, and other contraindications is required.
  • No compensation: Most participants do this on their own time or approved leave without extra pay.
  • Records: The signed form is not placed in your official personnel or electronic health record. It is stored separately per VHA records policy.
  • Voluntary nature: You can say no without any negative consequences.

Frequently Asked Questions About VA Form 10-10169

Is this human subjects research?
No. The form states that MRI pulse sequence testing for optimization is internal quality improvement, not research.

Can I change my mind after signing?
Yes. You may revoke consent at any time.

Will I get medical results from the scan?
No. This is not a diagnostic scan. You will not receive a full radiology report. Only significant incidental findings (if any) are noted on the form.

Who signs as the VA Official?
Usually a member of the Radiology Service staff who is obtaining your permission and overseeing the activity.

Helpful Resources

Here are trusted, current sources for VA Form 10-10169 and related information:

Final Tips

Always obtain the form directly from the official VA website or your local Radiology Service to ensure you have the current version. Read every section thoroughly and ask the Radiology staff any questions you have before signing. This process helps improve MRI imaging for veterans while protecting employee volunteers through clear consent and safety protocols.

This guide is based on the official VA Form 10-10169 (June 2019) and publicly available VA resources. It is for informational purposes only and is not a substitute for reading the complete form or receiving guidance from your VA facility’s Radiology Service or appropriate officials. Forms and procedures can be updated, so always verify the latest version on va.gov.