Information Collection

VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr

IC 204870 under ICR 201211-2900-008 · OMB 2900-0793.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0793 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA form 10-0491 VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr	Form
VA form 10-0491 HPSP/VIOMPSP Academic Verification 10-0491_Academic Verification.PDF To be determined	Form
VA Form 10-0491a HPSP/VIOMPSP Addendum to Application 10-0491a_Addendum to Application.pdf	Form
VA Form 10-0491c HPSP/VIOMPSP Annual VA employment deferment Verification 10-0491c_Annual VA Employment_Deferment Verification.pdf	Form
VA Form 10-0491d HPSP/VIOMPSP Education Program Completion Notice_Service 10-0491d_Education Program Completion Notice_Service Obligation Placement.pdf	Form
VA Form 10-0491e HPSP/VIOMPSP Evaluation Recommendation Form 10-0491e_Evaluation_Recommendation Form.pdf	Form
VA Form 10-0491f HPSP Agreement 10-0491f_HPSP Agreement.revised.pdf	Form
VA Form 10-0491g HPSP/VIOMPSP Application 10-0491g_HPSP_VIOMPSP Application.pdf	Form and Instruction
VA Form 10-0491h HPSP/VIOMPSP Notice of Approaching Graduation 10-0491h_Notice of Approaching Graduation.pdf	Form
VA Form 10-0491i HPSP/VIOMPSP Notice of Change and/or Annual Academic Sta 10-0491i_Notice of Change_Annual Academic Status Report.pdf	Form
VA Form 10-0491j HPSP/VIOMPSP Request for Deferment for Advanced Educatio 10-0491j_Request for Deferment for Advanced Education.pdf	Form
VA Form 10-0491k HPSP/VIOMPSP VA Scholarship Offer Response 10-0491k_VA Scholarship Offer Response.pdf	Form
VA Form 10-0491L VIOMPSP Agreement 10-0491L_VIOMPSP Agreement.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR Part 17 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA form 10-0491	HPSP/VIOMPSP Academic Verification	10-0491_Academic Verification.PDF	To be determined	Yes	No	Fillable Printable
Form	VA Form 10-0491a	HPSP/VIOMPSP Addendum to Application	10-0491a_Addendum to Application.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491c	HPSP/VIOMPSP Annual VA employment deferment Verification	10-0491c_Annual VA Employment_Deferment Verification.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491d	HPSP/VIOMPSP Education Program Completion Notice_Service Obligation Placement	10-0491d_Education Program Completion Notice_Service Obligation Placement.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491e	HPSP/VIOMPSP Evaluation Recommendation Form	10-0491e_Evaluation_Recommendation Form.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491f	HPSP Agreement	10-0491f_HPSP Agreement.revised.pdf	TBD	Yes	No	Fillable Printable
Form and Instruction	VA Form 10-0491g	HPSP/VIOMPSP Application	10-0491g_HPSP_VIOMPSP Application.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491h	HPSP/VIOMPSP Notice of Approaching Graduation	10-0491h_Notice of Approaching Graduation.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491i	HPSP/VIOMPSP Notice of Change and/or Annual Academic Status Report	10-0491i_Notice of Change_Annual Academic Status Report.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491j	HPSP/VIOMPSP Request for Deferment for Advanced Education	10-0491j_Request for Deferment for Advanced Education.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491k	HPSP/VIOMPSP VA Scholarship Offer Response	10-0491k_VA Scholarship Offer Response.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491L	VIOMPSP Agreement	10-0491L_VIOMPSP Agreement.pdf	TBD	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,500	6,500
Annual IC Time Burden (Hours)	32,689	32,689
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.