Information Collection

VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr

IC 204870 under ICR 202006-2900-006 · OMB 2900-0793.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0793 can be found here:

2023-02-17 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form VA Form 10-0491 VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr Form
VA Form 10-0491 HPSP Academic Verification vha-10-0491-fill (Academic Verification).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491a HPSP Addendum to Application vha-10-0491a-fill (Application Addendum).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491c HPSP Annual VA Employment or Deferment Verification vha-10-0491c-fill (Annual Deferment).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491d HPSP Education Program Completion Notice_Service Obligat vha-10-0491d-fill (Education Program Completion).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491e HPSP Evaluation Recommendation Form vha-10-0491e-fill (Evaluation and Recommendation).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491f HPSP Agreement vha-10-0491f-fill (HPSP Agreement)_revised per OMB passback_Feb 2020.pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491g HPSP Application vha-10-0491g-fill (Application).pdf vaww.va.gov/vaforms/ Form and Instruction
VA Form 10-0491h HPSP Notice of Approaching Graduation vha-10-0491h-fill (Notice of Approaching Graduation).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491i HPSP Notice of Change and/or Annual Academic Status Repo vha-10-0491i-fill (Notice of Change).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491j HPSP Request for Deferment for Advanced Education vha-10-0491j-fill (Deferment).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491k HPSP VA Scholarship Offer Response vha-10-0491k-fill (Offer Response).pdf vaww.va.gov/vaforms/ Form
VA Form 10-0491m HPSP Mobility Agreement vha-10-0491m-fill (Mobility Agreement).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr	Agency IC Tracking Number:	2900-0793

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR Part 17 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-0491	HPSP Academic Verification	vha-10-0491-fill (Academic Verification).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491a	HPSP Addendum to Application	vha-10-0491a-fill (Application Addendum).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491c	HPSP Annual VA Employment or Deferment Verification	vha-10-0491c-fill (Annual Deferment).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491d	HPSP Education Program Completion Notice_Service Obligation Placement	vha-10-0491d-fill (Education Program Completion).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491e	HPSP Evaluation Recommendation Form	vha-10-0491e-fill (Evaluation and Recommendation).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491f	HPSP Agreement	vha-10-0491f-fill (HPSP Agreement)_revised per OMB passback_Feb 2020.pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form and Instruction	VA Form 10-0491g	HPSP Application	vha-10-0491g-fill (Application).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491h	HPSP Notice of Approaching Graduation	vha-10-0491h-fill (Notice of Approaching Graduation).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491i	HPSP Notice of Change and/or Annual Academic Status Report	vha-10-0491i-fill (Notice of Change).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491j	HPSP Request for Deferment for Advanced Education	vha-10-0491j-fill (Deferment).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491k	HPSP VA Scholarship Offer Response	vha-10-0491k-fill (Offer Response).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491m	HPSP Mobility Agreement	vha-10-0491m-fill (Mobility Agreement).pdf		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Privacy Act of 1974, as amended	FR Citation: 71 FR 60232

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	-1,700	1,800
Annual IC Time Burden (Hours)	413	-6,583	6,996
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.