Fillable Printable VA Form 10-0491E

VA Form 10-0491E

Health Professional Scholarship Program (HPSP) &

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

Evaluation & Recommendation Form

OMB Number: 2900-0793

Estimated Burden: 50 minutes

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

Return this completed form to: HPSP/VIOMPSP Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113

HPSPVIOMPSPScholarship Program:

Academic FacultyEmployer (non-VA)VA EmployerOther

Evaluator (Print)

Title/Position

Institution/Organization (Name & Address)

1. How do you rate the educational/work achievement of this applicant? (Please provide written comments)

5 - Outstanding4 - Above Average3 - Average2 - Below Average1 - Poor

1 - Poor5 - Outstanding4 - Above Average3 - Average2 - Below Average

2 - Below Average3 - Average4 - Above Average5 - Outstanding1 - Poor

2. How do you rate the applicant's relationships with other people?

Consider such things as ability to work and get along with others. (Please provide written comments)

3. Based on this applicant's personal, emotional, ethical attributes, how do you rate his/her over-all potential for providing clinical services to our nation's

Veteran population? (Please provide written comments)

Evaluator (Signature)

Date

EVALUATION (Comments are strongly encouraged and will assist in the scoring of the applicant's application.)

Scholarship Recommendation:

Comments:

Relationship to applicant:Length of time known:

RecommendedNot Recommended

Conflict of Interest Statement:

Evaluation/Recommendation Type:

Comments:

Consent for Release of Information

CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my enrollment status and academic

standing, including grade point average, both now and while I am participating in the VA Health Professional Scholarship Program/Visual Impairment and Orientation

and Mobility Professionals Scholarship Program as well as the plan of study and projected costs. I understand that this authorization is voluntary, and that I may revoke

this consent at any time. However, I further understand that if I voluntarily revoke this authorization after the award of the scholarship, my scholarship award may be

terminated and I may be liable for the damages in accordance with provisions of 38 U.S.C. Sections 7505 and 7617. I authorize my prior employers and other

individuals who receive this form to release the requested information to the Department of Veterans Affairs.

Applicant's SignatureDate Signed

PAGE 1 of 1

I certify that I am not related to the applicant by blood or marriage.Initials:

The applicant identified above is applying to receive a Department of Veterans Affairs scholarship. The information on this form is requested pursuant to Title 38

United States Code, Sections 7501-7505, 7601-7619, and 7631-7636 as amended, and applicable program regulations. These governing documents provide that, in

evaluating and selecting individuals for scholarships, consideration will be given to faculty or employer recommendations.

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 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.

10-0491E

VA FORM

DEC 2013