VA Form 10-0491i HPSP Notice of Change and/or Annual Academic Status Repo

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)

Notice of Change and/or Annual Academic Status

(Please submit this form for any changes from the original application and annually to verify academic status.)
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 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

VHVMAESP

VIOMPSP

Annual Status/Progress Report Scholarship Participant's Name (Last, First, Middle): SSN (Last 4 Only):
Notice of Change

I am still enrolled in the school/program for which this scholarship was awarded and
do not have any changes to my original application/academic plan or previously
approved changes. (Attach a copy of your current transcript or grade report)
From:

Name Change

Changes to my original application/academic plan
are indicated below.

To:

Address Change New Address:
Supporting documentation is required for any changes identified below (new school fee schedule, etc.) More than one change may be selected.
Completion Date Change

From:

To:

Credit Hour Change

From:

To:

Course Change (List below)
Previously Scheduled

New Schedule

Semester/Quarter Start Date
Course #

Semester/Quarter Start Date

End Date

Course Title

Credits

Tuition

Course #

End Date

Course Title

Total

Credits

Tuition

Total

Repeat Previously Failed Coursework Course #:

Course Title:

Change in Total Projected Costs

From:

To:

Academic Probation

Request for Suspension

Start:

End:

Dismissed from School Date:

Leave of Absence

Start:

End:

USMLE Step 1 Passed

Date:

USMLE Step 2 Passed

Date:

Change from full-time status to less then full-time status

Date:

Voluntary withdrawal from course(s) during an academic term

Date:

School/Program change (Requires prior approval. Changes are strongly discouraged.)

Date:

Date:

New School/Program:
Reason for change(s) and planned actions other than change(s) noted above:

Participant's Signature:

Date

Advisor comments:

Annual enrollment and satisfactory status/progress verified:
Advisor's Signature:
Submit to:
VA FORM
DEC 2019

Advisor Disposition on proposed change(s)/actions:

Concur

Do not concur

Date
HPSP/VIOMPSP/VHVMAESP, Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113

10-00491I

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