VA Form 10-0491h HPSP Notice of Approaching Graduation

OMB Number: 2900-0793
Estimated Burden: 10 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)

Notice of Approaching Graduation

Submit this completed form to the Scholarship Program Office 6 months prior to graduation.
HPSP/VIOMPSP/VHVMAESP
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. §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
Student's Name (Last, First, Middle):

VIOMPSP

VHVMAESP

Social Security Number:

Clinical Program:

Email Address:

Type of Degree:

Expected Date
requirements will be met:

Scheduled
graduation date:

I verify the student's expected graduation information is accurate to the best of my knowledge.

Academic Advisor Signature
Please check applicable boxes:
I intend to begin my service obligation within 90 days after the educational and/or certification qualifications are met and I have
been accepted for an employment position. I do not intend to request a deferement of my service obligation.
I have submitted applications for employment at VA facilities for my service obligation.
(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)
I have been selected by a VA facility for my service obligation.
(Submit the Status Report on Service Obligation Placement form along with this Notification of Approaching Graduation.)
(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)
I have not submitted applications for employment at VA facilities for my service obligation.
I intend to submit my applications for employment no later than
Date
I intend to request a deferment of my service obligation in order to complete advanced clinical education.
(Submit the Request for Deferment form along with this Notification of Impending Graduation.)
(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)

Signature
VA FORM
DEC 2019

10-0491H

Date
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