19-264D Education Program Completion Notice

OMB Control No. 2900-XXXX
Estimated Burden: 20 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

EDUCATION PROGRAM COMPLETION NOTICE/
SERVICE OBLIGATION PLACEMENT

THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct
or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this
form will average 20 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) in order for VA to
determine the applicant's eligibility to receive a 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 the applicant's 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 process the applicant's request for a scholarship. If you give VA a social security number, VA will use it to obtain information
relevant to determining whether to grant a scholarship, and to administer the applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.

RCSSP

Service Obligation Report

Completion Notice

Participant's Name (Last, First, MI):

SSN:

COMPLETION INFORMATION

(Send copy of official transcript showing the degree conferred and copy of any related licensure/certification as applicable)
Degree Completed:
Date Degree Conferred
(MM/DD/YYYY):

Associate

Baccalaureate

Master's

Doctorate

Other

(Specify)

Clinical Program:

Date of Licensure/Certification
(MM/DD/YYYY):

SERVICE OBLIGATION SELECTION - Please complete if you have been selected for a position to fulfill your service obligation.
(Provide a copy of your Notification of Personnel Action (SF-50) to RCSSP as soon as it is available)

Name of VA Facility (actual work site facility):

Name of parent VA Facility (as applicable.):

Address of VA Facility (actual work site facility):

Address of parent VA Facility (as applicable):

Position Title:

Occupational Code:

Grade/Step:

Appointment/Start Date
(MM/DD/YYYY):

Full-Time

Yearly Salary:

Part-Time

Hiring Official (Person at the facility who is responsible for hiring you):
Hiring Official Name:

Title/Position:

Phone Number:

Email:

SERVICE OBLIGATION UPDATE - Please complete if you have not been selected for a position to fulfill your service obligation.
(Attach a separate page if more space is needed)

Application Date

(MM/DD/YYYY):

Facility/Position Location:

Vacancy Announcement and Title of Position:

Non-selection
No
Decision Attach copy of notification

FACILITY VACANCY - I have contacted the following VA facilities and was informed that the facility is not accepting applications or has no vacancies.
(Attach a separate page if more space is needed)

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Date (MM/DD/YYYY)

Signature

Submit to:
RCSSP, Readjustment Counseling Service (10RCS)
Department of Veterans Affairs
810 Vermont Ave., NW, Washington DC 20420

If you have any questions, please contact the Department of Veterans Affairs, Readjustment Counseling Service Clinical Team at
[email protected].
VA FORM
NOV 2021

10-264D

10RCS

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