VA Form 10-0491d HPSP Education Program Completion Notice_Service Obligat

OMB Number: 2900-0793
Estimated Burden: 20 minutes

Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility
Professionals Scholarship Program (VIOMPSP), & Veterans Healing Veterans Medical Access and
Education Scholarship Program (VHVMAESP)

Education Program Completion Notice/Service Obligation Placement

PRIVACY ACT NOTICE
The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7501 (VIOMPSP), §7611 (HPSP), and §7601 (VHVMAESP) 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 initiate the placement process to ensure service obligation completion. 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

Completion Notice

VIOMPSP

Service Obligation Report

SSN:

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

VHVMAESP
COMPLETION INFORMATION

Degree completed:

(Send copy of official transcript showing the degree conferred and copy of any related licensure/certification as applicable)

Associate

Date Degree Conferred:

Baccalaureate

Master's

Doctorate

Other

(Specify)

Clinical Program:

Date of Licensure/Certification:

SERVICE OBLIGATION SELECTION - Please complete if you have been selected for a position to fulfill your service obligation.
(Provide a copy of your Notification of Personnel Action (SF-50) to HPSP/VIOMPSP/VHVMAESP as soon as it is available)
Name of VA Facility (actual work site facility):

Name of parent VA Facility (as applicable.):

Address of VA Facility (actual work site facility):

Address of parent VA Facility (as applicable):

Position Title:

Occupational Code:

Grade/Step:

Appointment/Start Date:

Full-Time

Yearly Salary:

Part-Time
Hiring Official (Person at the facility who is responsible for hiring you):
Hiring Official Name:

Title/Position:

Phone Number:

Email:

SERVICE OBLIGATION UPDATE - Please complete if you have not been selected for a position to fulfill your service obligation.
(Attach a separate page if more space is needed)
Application
Date:

Facility/Position Location:

Vacancy Announcement and Title of Position:

No
Non-selection
Decision Attach copy of notification

FACILITY VACANCY - I have contacted the following VA facilities and was informed that the facility is not accepting applications or has no
vacancies. (Attach a separate page if more space is needed)
Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Signature
VA FORM
DEC 2019

Date

10-0491D

Submit to:
HPSP/VIOMPSP/VHVMAESP Department of VA
1250 Poydras St., Suite 1000, New Orleans, LA 70113
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