Form 28-1905 Authorization and Certification of Entrance or Reentranc

OMB Control No. 2900-0014
Respondent Burden: 5 Mins.

AUTHORIZATION AND CERTIFICATION OF ENTRANCE OR REENTRANCE INTO
REHABILITATION AND CERTIFICATION OF STATUS
NOTE: Before completing this form, read the instructions and other important information on the back.
SECTION A - IDENTIFYING DATA
1. NAME AND MAILING ADDRESS OF ENTITLED INDIVIDUAL

2. VA FILE NUMBER

.

.
3. SOCIAL SECURITY NUMBER

SECTION B - AUTHORIZATION TO FACILITY/VENDOR
4. NAME OF SERVICE/ASSISTANCE (Include degree type when applicable)
5. ENROLLMENT PERIOD

6. PLAN CODE

7. FACILITY CODE

8. NAME AND ADDRESS OF FACILITY OR SERVICE PROVIDER (Vendor)

9. SPECIFIC GUIDELINES (Restricted hours; courses
approved/not approved; restricted bookstore purchases;
tutoring approved; etc.)

10A. NAME OF CASE MANAGER OR DESIGNEE AND ADDRESS OF REGIONAL OFFICE 10B. E-MAIL ADDRESS OF CASE MANAGER

.

.

11A. SIGNATURE OF CASE MANAGER

11B. DATE SIGNED
12. VA BILLING ADDRESS

SECTION C - CERTIFICATION OF ATTENDANCE
13. I CERTIFY THAT the individual in Item 1 began or resumed the program shown in Item 4 on the beginning date for term 1 in Item 14A. He or
she continues to be pursuing or enrolled in that program. Charges for this program are in accordance with our current: (Check one)
VA CONTRACT OR AGREEMENT

SCHOOL CATALOG

OTHER PUBLISHED DOCUMENT

14. ENROLLMENT DATE

A.
TERM

B. BEGINNING DATE

C. ENDING DATE

D. TYPE AND
NUMBER OF HOURS E. TRAINING TIME
(S=semester
(F=full-time
Q=quarter
3/4=3/4-time
D=deficiency
1/2=1/2-time
R=residence
L=less than
C=clock/shop
1/2-time)
U=carnegie)

F. STANDARD CLASS
SESSION PER WEEK
(Only if less than the
term hours certified or
if the term is of
non-standard length)

1
2
3
4
15. LISTING OF SPECIFIC COURSES (In place of this list, you may attach a copy of registration or other documentation)

16A. SIGNATURE AND TITLE OF CERTIFYING OFFICIAL
VA FORM
JUN 2009

28-1905

EXISTING STOCKS OF VA FORM 28-1905, APR 2002,
WILL BE USED.

16B. DATE SIGNED

INSTRUCTIONS TO SCHOOL, ON-JOB TRAINING ESTABLISHMENT, OR OTHER FACILITY
This form authorizes this veteran or eligible person for training or services at your facility under Vocational
Rehabilitation (Chapter 31, title 38, U.S.C); Specialized Vocational Training, Special Restorative Training (Chapter 35,
title 38 U.S.C.); or Vocational Training for Certain Children With Spina Bifida or Other Covered Birth Defects (Chapter
18, title 38, U.S.C.). Under Chapters 18 and 31, but NOT under Chapter 35, the Department of Veterans Affairs will pay
for tuition, fees, books, and supplies for the program identified in Item 4. Item 9 lists specific guidelines regarding the
rehabilitation program for this individual. Forward vouchers for program expenses to the office in Item 10. VA pays in
arrears directly to the institution all vouchers for the veteran’s tuition, fees, books and supplies. The veteran under
Chapter 31 or child under Chapter 18 should not pay these expenses.
After the veteran or eligible person has enrolled or has begun his or her rehabilitation or training program or evaluation,
please complete all applicable items in the certification in Section C, sign and date the certification, and return the form
to the case manager or person in Item 10. Note these special instructions for completing the following items:

Item 14A. For schools or institutions providing training or instruction on a semester, quarter, or other
term basis, enter up to four terms, but do NOT enter a total enrollment period that exceeds 1 academic
year, including summer sessions if appropriate. If the individual’s vocational rehabilitation or training
plan projects attendance for the entire academic year, the school or institution should certify the entire
academic year.
Item 14D. For college-level courses organized on a term basis, enter the type and number of credit hours.
For other programs, enter the type and number of classroom and shop hours per week.
Item 14E. For each term, indicate the training time the facility considers that the number of hours in Item
14D represents.
Item 14F. Answer this item only if the facility organizes its classes in semesters, quarters, or other terms
and reports training time in credit-hours. For a detailed explanation of the relationship between standard
class sessions, nonstandard term lengths, and term hours, contact the VA regional office’s Education
Liaison Representative.
Item 15. You must complete this item for college-level or vocational training. This includes classroom
courses which supplement an on-job or apprentice training program. In place of an entry, you may attach
a copy of the individual’s registration or other documentation that details the courses the individual is
taking.
The case manager may also request that you submit additional information with this form.
For on-job training, you will also need to submit monthly either VA Form 28-1905c, Monthly Record of Training and
Wages, or VA Form 28-1917, Monthly Statement of Wages Paid to Trainee. The case manager will inform you which of
these forms you will have to submit.
PRIVACY ACT INFORMATION: No allowance of benefits for a veteran or eligible person may be granted unless the
information requested is furnished as required by existing law (38 U.S.C. 5101). The responses you submit are
considered confidential. They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is
authorized by the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22,
Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to
determine maximum benefits under the law. Information submitted is subject to verification through computer matching
programs with other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection
of information unless it displays a valid OMB Control Number. Public reporting burden for this collection of information
is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you
have comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000
for mailing information on where to send your comments.
VA FORM 28-1905, JUN 2009