VA Form 10-0491c HPSP/VIOMPSP Annual VA employment deferment Verification

OMB Number: 2900-0793
Estimated Burden: 10 minutes
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Annual VA Employment or Deferment Verification
HPSP/VIOMPSP: Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113
PRIVACY ACT NOTICE
The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order for VA to administer your scholarship award. VA
may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law
enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the
administration of VA training and scholarship programs, including verification of your eligibility to participate; and personnel administration. You do not have to provide
this information to VA but, if you do not, VA may be unable to continue your scholarship award. If you give VA your social security number, VA will use it to obtain
information relevant to administering your scholarship award. It also may be used for other purposes authorized or required by law.

HPSP

VIOMPSP

Participant's Name (Last, First, MI):

Address (Include Street Address, City, State, and ZIP Code):

Social Security Number:
Phone Number:
Email Address:

Clinical Program while in school:
Submitted for Annual Employment Verification
Attach a copy of your most recent Notification of Personnel Action
(SF-50) to this report.
Service Obligation Start Date:
My Current Position Title:

Date Degree Conferred:
Submitted for Annual Deferment Verification
Note: Submit "Education Program Completion Notice/Service Obligation
Placement" if the advanced education will be completed within 90 days.
Start date of the
Advanced Clinical
Education Program:

Anticipated Date
to begin Service
Obligation:

Grade and Step:

What year in the Advanced Clinical
Education has been Completed:

Total Number of Years
in the Program:

Name of VA Facility:

Name of Advanced Clinical Program:

Address of Facility (Include Street Address, City, State, and ZIP Code):

Address of Program (Include Street Address, City, State, and ZIP Code):

Note: Please check all applicable blocks below. If any of the blocks are not Note: Please check all applicable blocks below. If any of the blocks are not
applicable, please explain in the comments section.
applicable, please explain in the comments section.
I have continued full-time employment throughout my service
obligation.

I have continued in my Advanced Clinical Education Program.

I have not been on leave without pay during my service obligation.

I have received a satisfactory performance evaluation/review.

I do not anticipate any changes to my employment status during my
service obligation. If there is a change, I will notify the Scholarship
Program Office as soon as I become aware of anticipated changes.

I do not anticipate any changes to my educational status during my
deferment. If there is a change, I will notify the Scholarship Program
Office as soon as I become aware of anticipated changes.

I have received a satisfactory performance evaluation.
Comments:

Scholarship Participant's Signature

Date

Supervisor/Advisor Signature

Date

Supervisor/Advisor Title/Position

Phone

VA FORM
MAY 2017

10-0491C

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