VA Form 10-0491n HPSP VHVMAESP Agreement

OMB Number: 2900-0793
Estimated Burden: 15 minutes

VETERANS HEALING VETERANS MEDICAL ACCESS AND EDUCATION PROGRAM (VHVMAESP) AGREEMENT
INSTRUCTIONS: Do Not Make Alterations to this Document. Only
Use Ballpoint Pen to Complete.

8. Submit required documentation periodically to the Scholarship Office
at times determined by VA in order to continue receiving the scholarship
award. Notify VHVMAESP program officials of changes in address,
phone numbers, and enrollment status.

SECTION A - The Department of Veterans Affairs (VA) Veterans
Healing Veterans Medical Access and Education Program
(VHVMAESP) under 38 United States Code. Section 7601

9. Complete all coursework within the time frame indicated on the
application or any change in dates approved by the Scholarship Program.

SECTION B - Obligation of the Under Secretary for Health (USH).
1. Provide the undersigned participant with an VHVMAESP award
consisting of the payment of tuition, reasonable educational expenses, a
monthly stipend, and cost associated with attending two rotations at a
VA facility as authorized by 38 U.S.C. Section 7601
2. Ensure that each participant selected for the VHVMAESP is an
eligible applicant, pursuing a degree in a qualifying field of education
or training designated by the USH for participation in the program.
3. Appoint the participant to a full-time position providing health
services in accordance with Section C12 of this agreement. This
employment will begin within 90 days after the participant completes
post graduate training and meets all the applicable qualification and
licensure requirements for appointment to the position. This time
period may be extended at the USH's discretion. At least 60 days prior
to the appointment date, the participant will be notified of location and
beginning date of obligated service.
4. Assign a mentor to the scholarship participant when it is determined
when and where the participant will be performing the obligated
service. The mentor will be employed at the same facility where the
participant will complete the obligated service.
SECTION C - Obligation of the Participant. In return for payments
under the VHVMAESP, the participant agrees to:
1. Accept the VHMAESSP award provided by the USH under Section
B1 of this agreement for 4-years.
2. Pursue a degree in a qualifying field of education or training
designated by the USH for participation in the scholarship program and
the degree designated in the application for the scholarship program.
3. Maintain enrollment as specified in the scholarship application until
completion of the course of study for which the scholarship award is
provided.
4. Maintain an acceptable level of academic standing, as determined
by the educational institution, while enrolled in the course of study for
which the scholarship award is provided.

10. Ensure that the VHVMAESP program officials have access to
educational or training institution official transcripts, and other
information and documents required to assess the academic standing,
status, and progress of the scholarship recipient.
11. Sign a mobility agreement in which the participant agrees to relocate,
if necessary, at his or her own expense, to complete a clinical tour or
service obligation period.
12. Perform a clinical tour in a VA assignment or location determined by
the USH while enrolled in the course of study for which the scholarship
was awarded.
13. Serve a period of obligated service.
a. All scholarship participants in the VHVMAESP must serve a 4year period of obligated service as a full-time employee in the
Veterans Health Administration (VHA) in an assignment and
location determined by the USH.
b. This employment will begin within 90 days after the participant
completes post-graduate training and meets all the applicable
qualification requirements for appointment to the position.
c. If the participant requests a deferment, an additional period of
service obligation may be required, at the discretion of the USH.
No credit of time for any advanced clinical training will be counted
toward satisfying the obligated service period.
14. Recipients of the VHVMAESP scholarship agree to not receive any
educational benefits under 38 United States Code chapters 30-35
and under 10 United States Code chapters 1606 and 1607, while
receiving awards from the VHVMAESP.
SECTION D - Breach of VHVMAESP Agreement. If a participant, defined
as an applicant who has been selected for and accepted a scholarship
award:
1. Fails to accept payment or instructs the educational institution to
which the scholarship payments are to be made not to accept payments
under this agreement, the participant (other than a participant under
paragraph 2 of this section) shall, in addition to the service or other
obligations incurred under this agreement, pay to the United States the
sum of $1,500 as liquidated damages. Payment of this amount must be
made within one year of the date on which the participant fails to accept
payment of the VHVMAESP award or instructs the school not to accept
payment.

5. Notify the Scholarship Program office in writing, of any of the
following changes within 10 days: change in name, address, telephone
number, enrollment status, plan of study, or academic standing.
6. Scholarship recipients may not change school or program without
prior approval from the VHVMAESP Program Office.
7. In the case of a participant who is enrolled in a program or education
or training leading to employment as a physician, the participant must
successfully complete postgraduate training leading to eligibility for
board certification in a specialty identified by the Secretary.
VA FORM
DEC 2019

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Applicant's Name:

Applicant Initial

VETERANS HEALING VETERANS MEDICAL ACCESS AND EDUCATION PROGRAM (VHVMAESP) AGREEMENT (cont.)
2. Fails to maintain an acceptable level of academic standing in the
course of study for which the award is provided; is dismissed from the
educational institution for disciplinary reasons, voluntary terminates for
any reason, the course of study or program for which the award was
granted, including a reduction of course load from full-time to part-time,
before completing the course of study; fails to meet the requirements for
licensure and board eligibility in a specialty after the completion of postgraduate training, or fails to meet any applicable licensure requirement in
either direct patient-care services or services incident to direct patientcare services, during a period of time determined under regulations
prescribed by the USH.
3. Breaches the agreement by failing for any reason to begin or complete
such participant's period of obligated service, or by failure to comply with
the terms and conditions of deferment; the United States shall be entitled
to recover from the participant an amount equal to the amount of such
funding received by the recipient.
The amount the United States is entitled to recover may be offset against
any salary, wages, accrued leave or retirement annuity which the
participant is owed at the time the participant was terminated or failed to
complete the required obligated service.
Payment of this amount must be made within one year from the date of
breach.
SECTION E - Cancellation, Suspension, and Waiver of Obligation.
1. Any service or payment obligation incurred under this agreement will
be canceled upon the death of the participant.
2. The USH may waive or suspend the participant's service or payment
obligation incurred under this agreement if:
a. Compliance by the participant with the terms and conditions of the
agreement is impossible due to circumstances beyond the control of
the participant, or
b. In cases not related to paragraph 2.a. of this Section, when
considered in the best interest of the VA. Such decisions will be
made by the USH on an individual basis.
3. Requests for waiver of obligation must be submitted to the USH
within one year of the date the participant is determined, by the USH, to
be in breach of the agreement.
SECTION F - Consent for Release of Information.
The undersigned participant consents to allow the educational institution
to report status and academic standing including grade point average at
the time of application and, if selected, during the period of award
participation. The participant understands that this authorization is
voluntary and the participant may revoke the consent at any time.
However, the participant further understands that if this authorization is
voluntarily revoked after the award of the scholarship, the scholarship
award may be terminated and the participant may be liable for damages in
accordance with provisions of Section 7617, Title 38, United States Code.

VA FORM
DEC 2019

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SECTION G - General Provisions.
The Under Secretary for Health or authorized representative must
accept this agreement before it becomes effective. The regulations and
other documents issued by the Under Secretary for Health to
implement the HPSP are incorporated into and made a part of this
agreement.

I understand the period of obligated service for this agreement is
I have read and understand the above agreement. I agree to comply
with the published statutes, regulations and policies governing the
Veterans Healing Veterans Medical Access and Education
Scholarship Program and to be subject to any changes in program
policy.

Applicant's Name (Print)
Applicant's Signature

Date

Signature of Under Secretary for Health (USH)
or, Authorized Representative

Date