Form VA Form 28-1905 VA Form 28-1905 Authorization and Certification of Entrance or Reentranc

OMB Control No. 2900-0014
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/XXXX

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.)
Use addendum to Item 9 on Page 2 for additional space.

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
A.
TERM

SCHOOL CATALOG

OTHER PUBLISHED DOCUMENT

14. ENROLLMENT DATE
B. BEGINNING DATE

C. ENDING DATE

1
2
3
4

D. TYPE AND
NUMBER OF HOURS
(S=semester
Q=quarter
D=deficiency
R=residence
C=clock/shop
U=carnegie)

E. TRAINING
TIME
(F=full-time
3/4=3/4-time
1/2=1/2-time
L=less than
1/2-time)

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

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
XXX XXXX

28-1905

EXISTING STOCKS OF VA FORM 28-1905, FEB 2017,
WILL BE USED.

16B. DATE SIGNED
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NAME OF VETERAN (First, middle, last)

SOCIAL SECURITY NO./VA FILE NO.

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

VA FORM 28-1905, XXX XXXX

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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: VA will not disclose information collected on this form to any source other than what has been
authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e. to obtain information to
document type and number of hours of the veteran's training status) as identified in the VA system of records, 58VA21/22/28,
Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.
Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are
required to provide their SSN under Title 38 U.S.C. 5101 (c)(1). VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine or confirm the proper subsistence allowance rate payable to the
trainee. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to
review the instructions, find the information, and completed this form. VA cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
Valid OMB coltrol numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 28-1905, XXX XXXX

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