VA Form 10-0491i, NOTICE OF CHANGE (NOC)

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OMB Control No. 2900-0793
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/20XX

Health Professional Scholarship Program (HPSP), Visual Impairment and
Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

NOTICE OF CHANGE (NOC)
The purpose of completing a notice of change form is to maintain good standing in the HPSP Scholarship Program. HPSP recipients are required at a minimum to
complete the NOC monthly along with monthly check-ins while enrolled in the program of study or during academic breaks in which the scholarship awarded was for.
Items with an * next to the option require proof of documentation and in such cases meeting with the HPSP Scholarship Program if there are questions about a
recipient’s status in the scholarship program or have a financial impact that may result in a bill of collection issued to the recipient. Itemized are instructions based on
the type of change option selected by the recipient.
No changes: Recipient is attesting that no changes are made and remain in good academic standing.
Minor Notice of Change: Recipient is changing their name, address, contact information, or email address. NOTE: For physical address changes, the recipient is
responsible for updating their information in the VA Customer Engagement Portal (CEP) where direct deposits/EFT occur.
Major Notice of Change: Depending on the change will determine the requirements and proof of documentation. For some changes, a recipient may be required to meet
with the HPSP Program Office as the change may result in a breach in the contract and change the recipient’s standing in the program.
For a request for suspension, proof of documentation is required. NOTE: Suspensions are valid for up to one (1) year and available to use two (2) times throughout a
recipient’s duration in the HPSP Scholarship Program. For enrollment status (i.e. full-time to part-time) in the program of study, recipients are not eligible to receive
monthly stipends. For a leave of absence, all monthly stipends/annual book stipends will be temporarily paused to avoid erroneous and/or overpayments while the
recipient is not enrolled/active in the program of study.
For voluntarily terminating/withdrawing or dismissed from the academic institution/program of study, the HPSP recipient status changes to breach and issued a bill of
collection. NOTE: Recipients need to provide proof of documentation and meet with the HPSP Program Office. For academic institution (school) changes, preauthorization is required by the HPSP Program Manager or designee prior to the recipient transfers. Failure to receive pre-authorization by the HPSP Program Manager
or designee will result in a recipient’s status change to breach and issued a bill of collection.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7501 (VIOMPSP), §7611 (HPSP) for VA
to administer your 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 your 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 continue your scholarship award. If you give VA your social
security number, VA will use it to obtain information relevant to administering your scholarship award. It also may be used for other purposes authorized or required by
law.
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0793, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 20 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No.
2900-0793 in any correspondence. Do not send your completed VA Form 10-0491i to this email address.
HPSP

NO CHANGE/GOOD ACADEMIC STANDING

VIOMSP

MINOR CHANGE

VET CENTER

MAJOR CHANGE

SCHOLARSHIP PARTICIPANT'S NAME (Last, First, Middle)

NAME CHANGE
FROM:

SSN (Last 4 Only)

NAME CHANGE
TO:
ADDRESS CHANGE

ADDRESS CHANGE
TO:

FROM:
EMAIL ADDRESS CHANGE
FROM:

EMAIL ADDRESS CHANGE
TO:

PROJECTED COURSE COST CHANGE FROM:

PROJECTED COURSE COST CHANGE TO:

REPEAT COURSE

ANTICIPATED SEMESTER/TERM TO RETAKE REPEATED COURSE

TITLE/COURSE NUMBER:

SEMESTER/TERM:

NOTE: HPSP Program does not cover or reimburse.

NOTE: HPSP Program does not cover or reimburse.

CHANGE IN GRADUATION DATE

CHANGE IN GRADUATION DATE

FROM (MM/DD/YYYY):

TO (MM/DD/YYYY):

NOTE: Requires updating course schedule/academic terms and academic advisor
review and concurrence

NOTE: Requires updating course schedule/academic terms and academic advisor
review and concurrence

ACADEMIC PROBATION
TERM/DATE (MM/DD/YYYY):
VOLUNTARY WITHDREW FROM COURSE(S) DURING ACADEMIC TERM
TERM/DATE (MM/DD/YYYY):
VA FORM
XXX 20XX

10-0491i

REMEDIAL COURSE OF ACTION
EXPECTED DATE FOR PROBATION STATUS TO CHANGE (MM/DD/YYYY):
ENROLLMENT STATUS CHANGE FROM FULL-TIME TO LESS THAN FULLTIME
TERM/EFFECTIVE DATE (MM/DD/YYYY):

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VOLUNTARY WITHDREW FROM THE PROGRAM OF STUDY OR ACADEMIC
INSTITUTION
TERM/DATE (MM/DD/YYYY):
LEAVE OF ABSENCE (LOA)

DISMISSED FROM THE PROGRAM OF STUDY OR ACADEMIC INSTITUTION
TERM/EFFECTIVE DATE (MM/DD/YYYY):

NOTE: Requires proof of documentation and meeting with HPSP Program Office.
LEAVE OF ABSENCE (LOA)

FROM:

TO:

NOTE: Requires proof of documentation/academic advisor concurrence.

NOTE: Requires proof of documentation/academic advisor concurrence.

REQUEST FOR SUSPENSION

REQUEST FOR SUSPENSION

FROM:

TO:

NOTE: Requires proof of documentation/HPSP Program Office concurrence.

NOTE: Requires proof of documentation/HPSP Program Office concurrence.

SCHOOL CHANGE

FROM:

NEW SCHOOL

ANTICIPATED START DATE (MM/DD/YYYY):

NOTE: Requires HPSP Program Manager or designee pre-authorization prior to recipient re-enrolling/readmission to another school). Failure to receive preauthorization results in breaching the contract and meeting with HPSP Program Office.
ONLY APPLICABLE TO HPSP PHYSICIAN RECIPIENTS
USMLE STEP 1

PASSED DATE (MM/DD/YYYY):

USMLE STEP 2

PASSED DATE (MM/DD/YYYY):

PARTICIPANT COMMENTS:

PARTICIPANT SIGNATURE:

ADVISOR COMMENTS:

ADVISOR SIGNATURE:

VA FORM 10-0491i, XXX 20XX

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