Fillable Printable VA Form 10-0491f
Fillable Printable VA Form 10-0491f
VA Form 10-0491f
HEALTH PROFESSIONAL SCHOLARSHIP PROGRAM (HPSP) AGREEMENT
INSTRUCTIONS: Do Not Make Alterations to this Document. Only
Use Ballpoint Pen to Complete.
SECTION A - The Department of Veterans Affairs (VA) Health
Professional Scholarship Program (HPSP) is described in 38 United
States Code, Sections 7601-7619 and 7631-7636.
SECTION B - Obligation of the Under Secretary for Health (USH).
Subject to availability of funds appropriated by the Congress of the
United States, the Under Secretary for Health agrees to:
1. Provide the undersigned participant with an HPSP award consisting
of the payment of tuition, reasonable educational expenses, and a
monthly stipend, as authorized by 38 U.S.C. §7613.
2. Ensure that each participant selected for the HPSP 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 C13 of this agreement. This
employment will begin within 90 days after the participant completes
the HPSP-supported education or 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 HPSP, the participant agrees to:
1. Accept the HPSP award provided by the USH under Section B1 of
this agreement.
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.
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. (Current VA employees only) Maintain VA employment while
enrolled part-time in the course of education or training for which the
scholarship is provided if selected for the part-time scholarship
program as a full-time VA employee.
7. (Current VA employees only) Maintain an acceptable level of work
performance and conduct prior to beginning their service obligation
period.
8. Submit required documentation periodically to the Scholarship Office
at times determined by VA in order to continue receiving the scholarship
award. Notify HPSP program officials of changes in address, phone
numbers, and enrollment status.
9. Complete all coursework within the time frame indicated on the
application or any change in dates approved by the Scholarship Program.
10. Ensure that the HPSP 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 in accordance with Sections C12 and 13 of this
agreement.
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 HPSP must serve a 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 the HPSP-supported education or 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.
d. A full-time student will incur a service obligation of one year for
each school year or part thereof, but for not less than two years.
e. (Current VA employees only) Per 38 U.S.C. §7672, "In the case of
a participant who is a part-time student, the period of obligated
service shall be reduced in accordance with the proportion that the
number of credit hours carried by such participant in any such
school year bears to the number of credit hours required to be
carried by a full-time student in the course of training being
pursued by the participant, but in no event to less than one year."
SECTION D - Breach of HPSP 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
Applicant Initial
Applicant's Name:
OMB Number: 2900-0793
Estimated Burden: 15 minutes
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10-0491F
DEC 2013
VA FORM
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 HPSP award or instructs the school not to accept payment.
2. Fails to maintain any obligation specified in Section C; 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; voluntarily terminates, for any reason,
the course of study or program for which the award was granted including
a reductionof course load from full-time to part-time before completing
the course of study; fails to become licensed and/or certified in
theoccupation for which the education and training was provided within
one year from the date such person becomes eligible to apply for the
licensure, or fails to meet any applicable licensure requirement in the case
of any other healthcare personnel who provide either direct patient-care
services or services incident to direct patient-care services, during a
period of time determined under regulations prescribed by the USH; or,
fails to maintain employment, while enrolled as a part-time student in the
course of training being pursued under the HPSP as a Department
employee. In such cases the participant shall, instead of performing the
service obligation incurred under this agreement, repay to the United
States all funds paid to the participant under this agreement. Payment of
this amount must be made within one year from the date of breach.
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 of triple damages determined in
accordance with the following formula:
A=3P((t-s)/t) in which
"A" is the amount the United States is entitled to recover;
"P" is the sum of:
a. The amounts paid under this agreement, to or on behalf of the
participant; and
b. The interest on such amounts which would be payable if at the time
the amounts were paid they were loans bearing interest at the maximum
legal prevailing rate, as determined by the Treasurer of the United States.
"t" is the total number of months in the participant's period of obligated
service, including any additional period of obligated service in
accordance with Section 7616(b)(4), Title 38, United States Code.
"s" is the number of months of such period served by the participant in
accordance with Section 7613, Title 38, United States Code. The amount
the United States is entitled to recover shall be paid within one year of the
date the USH determines that the participant has failed to begin or
complete the period of obligated service.
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.
SECTION E - Cancellation, Suspension, and Waiver of Obligation.
1. Any service or payment obligation incurred under this agreement will
be cancelled 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.
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.
HEALTH PROFESSIONALS SCHOLARSHIP PROGRAM (HPSP) AGREEMENT (continued)
Date
Date
Applicant's Name (Print)
I understand the period of obligated service for this agreement is
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I have read and understand the above agreement. I agree to comply
with the published statutes, regulations and policies governing the
Health Professional Scholarship Program and to be subject to any
changes in program policy.
10-0491F
DEC 2013
VA FORM
Applicant's Signature
Signature of Under Secretary for Health (USH) or,
Authorized Representative
