Form 28-1905h Trainee Request for Leave (Chapter 31, Veteran Readiness

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

TRAINEE REQUEST FOR LEAVE
(Chapter 31, Veteran Readiness and Employment)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to submit a
statement for a request for a leave of absence. 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.

SECTION I: CLAIMANT'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite the processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER

3. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

Apt./Unit Number
State/Province

City
Country

ZIP Code

4. TELEPHONE NUMBER (Include Area Code)

5. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence
from VA in regards to my claim.

Enter International Phone Number (If applicable)

SECTION II: TRAINING ESTABLISHMENT OR SCHOOL
(To include educational institutions, rehabilitation centers, Non-Paid Work Experience, apprenticeship, and on-job training sites)
6. NAME OF TRAINING ESTABLISHMENT OR SCHOOL

7. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

Apt./Unit Number
State/Province

City
Country

8. TELEPHONE NUMBER (Include Area Code)

ZIP Code
9. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence
from VA in regards to my claim.

Enter International Phone Number (If applicable)

SECTION III: REQUEST FOR LEAVE OF ABSENCE
10. FIRST DAY OF LEAVE (MM/DD/YYY)

11. LAST DAY OF LEAVE (MM/DD/YYY)

12. IF REQUEST IS FOR ILLNESS OR INJURY, STATE NATURE OF ILLNESS OR INJURY

VA FORM
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28-1905h

SUPERSEDES VA FORM 28-1905h, JUN 2018,
WHICH WILL NOT BE USED.

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SECTION IV: (To Be Completed by Trainer or Authorized School Official)
13.

ABSENCE OF ABOVE-NAMED CLAIMANTS ON DATES
INDICATED WILL (OR DID) NOT MATERIALLY
INTERFERE WITH PROGRESS IN THE COURSE. I
RECOMMEND APPROVAL OF THIS REQUEST.

ABSENCE OF ABOVE-NAMED CLAIMANT ON DATES
INDICATED WILL (OR DID) MATERIALLY INTERFERE
WITH PROGRESS IN THE COURSE. I DO NOT
RECOMMEND APPROVAL OF THIS REQUEST.

14. REMARKS

SECTION V: CERTIFICATION OF STATEMENT AND SIGNATURE

I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
15. TITLE OF TRAINER OR AUTHORIZED SCHOOL OFFICIAL

16. SIGNATURE OF TRAINER OR AUTHORIZED SCHOOL OFFICIAL

16A. DATE SIGNED (MM/DD/YYYY)

17. CLAIMANT SIGNATURE

17A. DATE SIGNED (MM/DD/YYYY)

SECTION VI: (To Be Completed by VA Case Manager)
18. ACTION TAKEN
APPROVED

19. DATE VETERAN NOTIFIED (MM/DD/YYYY)
DISAPPROVED

20. SIGNATURE OF VA CASE MANAGER

21. DATE SIGNED (MM/DD/YYYY)

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: The form is used by the claimant and the trainer to provide sufficient information to justify a leave of absence (U.S.C. 3110). 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
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28-1905h

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