Fillable Printable VA Form 10-0491C

VA Form 10-0491C

I have received a satisfactory performance evaluation.

Social Security Number:

Annual VA Employment or Deferment Verification

OMB Number: 2900-0793

Estimated Burden: 10 minutes

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

Total Number of Years

in the Program:

Start date of the

Advanced Clinical

Education Program:

What year in the Advanced Clinical

Education has been Completed:

Name of Advanced Clinical Program:

Anticipated Date

to begin Service

Obligation:

Address of Program (Include Street Address, City, State, and ZIP Code):

Address (Include Street Address, City, State, and ZIP Code):

Scholarship Participant's Signature

Date

Email Address:

Phone Number:

Clinical Program while in school:

Address of Facility (Include Street Address, City, State, and ZIP Code):

Date Degree Conferred:

Name of VA Facility:

My Current Position Title:

Supervisor/Advisor Signature

Supervisor/Advisor Title/Position

Date

Phone

Comments:

Attach a copy of your most recent Notification of Personnel Action

(SF-50) to this report.

Service Obligation Start Date:

Grade and Step:

I have continued full-time employment throughout my service

obligation.

I have received a satisfactory performance evaluation/review.

I do not anticipate any changes to my educational status during my

deferment. If there is a change, I will notify the Scholarship Program

Office as soon as I become aware of anticipated changes.

I have continued in my Advanced Clinical Education Program.

I have not been on leave without pay during my service obligation.

I do not anticipate any changes to my employment status during my

service obligation. If there is a change, I will notify the Scholarship

Program Office as soon as I become aware of anticipated changes.

Note: Please check all applicable blocks below. If any of the blocks are not

applicable, please explain in the comments section.

Note: Please check all applicable blocks below. If any of the blocks are not

applicable, please explain in the comments section.

Note: Submit "Education Program Completion Notice/Service Obligation

Placement" if the advanced education will be completed within 90 days.

Submitted for Annual Employment Verification Submitted for Annual Deferment Verification

HPSP VIOMPSP

HPSP/VIOMPSP: Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113

Health Professional Scholarship Program (HPSP) &

Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

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PRIVACY ACT NOTICE

The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order 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.

10-0491C

VA FORM

DEC 2013