Form VA Form 28-1904 VA Form 28-1904 On-The-Job Training Agreement

OMB Control No. 2900-0678
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(For VA Use Only)

ON-THE-JOB TRAINING AGREEMENT
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on
page 2. Use this form to outline an on-the-job training agreement. For more information, contact us
at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are
available at www.va.gov/vaforms. After completing the form if returning by mail, mail to: Veteran
Readiness and Employment (VR&E) Intake Center, Department of Veterans Affairs, P.O. Box
5210, Janesville, WI, 53547-5210.

NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.

THIS AGREEMENT, entered into as of the

day of

between Legal Name

, 20

and Address of Establishment)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

(hereinafter referred to as the Establishment) and the Department of Veterans Affairs (VA) for the purpose of
implementing the provisions of Chapter 31, Title 38, U.S. Code with reference to on-the-job training to
claimants with disabilities:
1. That the Establishment will:
a. Accept, from time to time and within its own discretion in each case, claimants with disabilities for a course of
training on-the-job which will render each employable in accordance with the provisions of law for the following
job objectives:
LENGTH IN MONTHS
JOB OBJECTIVE

VA FORM
XXX XXXX

28-1904

SUPERSEDES VA FORM 28-1904, APR 2015,
WHICH WILL NOT BE USED.

Page 1

2. That the Department of Veterans Affairs will:
a. Enter claimants as they are eligible and available into those on-the-job training programs in which the
Establishment will accept them.
b. Exercise supervision of the claimants in on-the-job training to the extent necessary to protect the interest
of the Federal Government and the claimants.
c. Furnish to each claimant, at the expense of VA, such books, tools, equipment, and materials, in addition to
any supplied by the Establishment, commonly required by the Establishment to be supplied and personally
owned by other trainees but not generally provided by the Establishment, not under VA jurisdiction, pursuing
the same on-the-job training in the Establishment.
d. Assume the responsibility of keeping the Establishment currently informed of any, and all modifications of the
law and the VA regulations affecting the on-the-job training program for claimants with disabilities.
e. Remove from on-the-job training status any claimant whose personal conduct, lack of application to his or her
on-the-job training, or unsatisfactory quality of work is such as to jeopardize the interest of the claimant, the
Establishment, or the VA, provided, however, that when a claimant is being trained under terms of this
agreement, the terms of such agreement shall control insofar as such terms are not incompatible with the
provision of law governing the claimant's on-the-job training, or with interests or policies of VA.
3. Further, that:
a. Each claimant in on-the-job training under this agreement will be under the control and supervision of the
Establishment and will be subject to the same rules and regulations governing the conduct of other comparable
employees of the Establishment.
b. This agreement may be terminated by the Establishment or the VA with a 15 day notice period.
CERTIFICATION OF STATEMENT AND SIGNATURE FOR THE ESTABLISHMENT
I CERTIFY THAT I have completed this statement and that the information is true and correct to the best of my knowledge and belief.
4A. NAME AND TITLE

4C. DATE SIGNED (MM-DD-YYYY)

4B. SIGNATURE

CERTIFICATION FOR THE DEPARTMENT OF VETERANS AFFAIRS
5A. NAME AND LOCATION OF VA REGIONAL OFFICE

5B. SIGNATURE OF VETERAN READINESS AND EMPLOYMENT
REPRESENTATIVE

5C. DATE SIGNED (MM-DD-YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know
to be false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits. 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., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and
status, and personnel administration) 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. Information that you furnish may be utilized in computer matching programs with other Federal or State
agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in
any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: This form is used to outline a training agreement for on-the-job training (38 U.S.C. 3014). Title 38, United States Code allows us to ask for this
information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor
a collection of information unless a valid OMB control number is displayed. Valid OMB 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 28-1904, XXX XXXX

Page 2