Information Collection

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

IC 204870 under ICR 202212-2900-003 · OMB 2900-0793.

Documents and Forms

Documents and forms in this information collection
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/VIOMPSP Academic Verification vha-10-0491-fill (Academic Verification).pdf vaww.va.gov/vaforms/	Form
VA form 10-0491 HPSP/VIOMPSP Academic Verification vha-10-0491-fill (Academic Verification).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491a HPSP/VIOMPSP Addendum to Application vha-10-0491a-fill (Application Addendum).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491a HPSP/VIOMPSP Addendum to Application vha-10-0491a-fill (Application Addendum).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491c HPSP/VIOMPSP Annual VA Employment Deferment Verification vha-10-0491c-fill (Annual Deferment).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491c HPSP/VIOMPSP Annual VA Employment Deferment Verification vha-10-0491c-fill (Annual Deferment).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491d HPSP/VIOMPSP Education Program Completion Notice_Service vha-10-0491d-fill (Education Program Completion).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491d HPSP/VIOMPSP Education Program Completion Notice_Service vha-10-0491d-fill (Education Program Completion).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491e HPSP/VIOMPSP Evaluation Recommendation Form vha-10-0491e-fill (Evaluation and Recommendation).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491e HPSP/VIOMPSP 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 10-0491f 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/VIOMPSP Application vha-10-0491g-fill (Application).pdf vaww.va.gov/vaforms/	Form and Instruction
VA Form 10-0491g HPSP/VIOMPSP Application vha-10-0491g-fill (Application).pdf vaww.va.gov/vaforms/	Form and Instruction
VA Form 10-0491h HPSP/VIOMPSP Notice of Approaching Graduation vha-10-0491h-fill (Notice of Approaching Graduation).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491h HPSP/VIOMPSP Notice of Approaching Graduation vha-10-0491h-fill (Notice of Approaching Graduation).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491i HPSP/VIOMPSP Notice of Change and/or Annual Academic Sta vha-10-0491i-fill (Notice of Change).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491i HPSP/VIOMPSP Notice of Change and/or Annual Academic Sta vha-10-0491i-fill (Notice of Change).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491j HPSP/VIOMPSP Request for Deferment for Advanced Educatio vha-10-0491j-fill (Deferment).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491j HPSP/VIOMPSP Request for Deferment for Advanced Educatio vha-10-0491j-fill (Deferment).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491k HPSP/VIOMPSP VA Scholarship Offer Response vha-10-0491k-fill (Offer Response).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491k HPSP/VIOMPSP VA Scholarship Offer Response vha-10-0491k-fill (Offer Response).pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491L VIOMPSP Agreement vha-10-0491L-fill (VIOMPSP Agreement)_revised per OMB passback_Feb 2020.pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491L VIOMPSP Agreement vha-10-0491L-fill (VIOMPSP Agreement)_revised per OMB passback_Feb 2020.pdf vaww.va.gov/vaforms/	Form
VA Form 10-0491m HPSP/VIOMPSP Mobility Agreement vha-10-0491m-fill (Mobility Agreement).pdf	Form
VA Form 10-0491m HPSP/VIOMPSP Mobility Agreement vha-10-0491m-fill (Mobility Agreement).pdf	Form
VA Form 10-0491n HPSP VHVMAESP Agreement vha-10-0491n-fill (VHVMAESP Agreement)_revised per OMB passback_Feb 2020.pdf	Form
VA Form 10-0491n HPSP VHVMAESP Agreement vha-10-0491n-fill (VHVMAESP Agreement)_revised per OMB passback_Feb 2020.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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA form 10-0491	HPSP/VIOMPSP Academic Verification	vha-10-0491-fill (Academic Verification).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491a	HPSP/VIOMPSP 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/VIOMPSP Annual VA Employment Deferment Verification	vha-10-0491c-fill (Annual Deferment).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491d	HPSP/VIOMPSP 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/VIOMPSP 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/VIOMPSP Application	vha-10-0491g-fill (Application).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491h	HPSP/VIOMPSP 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/VIOMPSP 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/VIOMPSP 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/VIOMPSP VA Scholarship Offer Response	vha-10-0491k-fill (Offer Response).pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491L	VIOMPSP Agreement	vha-10-0491L-fill (VIOMPSP Agreement)_revised per OMB passback_Feb 2020.pdf	http://vaww.va.gov/vaforms/	Yes	Yes	Fillable Printable
Form	VA Form 10-0491m	HPSP/VIOMPSP Mobility Agreement	vha-10-0491m-fill (Mobility Agreement).pdf		Yes	Yes	Fillable Printable
Form	VA Form 10-0491n	HPSP VHVMAESP Agreement	vha-10-0491n-fill (VHVMAESP Agreement)_revised per OMB passback_Feb 2020.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: 1,950

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,950	150	1,800
Annual IC Time Burden (Hours)	7,619	623	6,996
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.