Fillable Printable VA Form 10-0491L
Fillable Printable VA Form 10-0491L
VA Form 10-0491L
VA VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY PROFESSIONALS SCHOLARSHIP PROGRAM (VIOMPSP)
AGREEMENT
INSTRUCTIONS: Do Not Make Alterations to this Document. Only
Use Ballpoint Pen to Complete.
SECTION A - The Department of Veterans Affairs (VA) Visual
Impairment and Orientation and Mobility Professionals Scholarship
Program (VIOMPSP) is described in 38 United States Code, Sections
7501-7505.
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 a VIOMPSP award
consisting of the payment of tuition and required fees as determined by
the USH as being necessary with a maximum of $15,000 per academic
year for a full-time student. The maximum amount will be prorated for
part-time students.
2. Ensure that each participant selected for the VIOMPSP 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 Sections C10 and C11 of this agreement.
This employment will begin within 90 days after the educational and/or
certification qualification standards are met by the participant. The
USH shall carry out the program to fully employ scholarship graduates
as soon as possible upon graduation and completion of necessary
certifications and will assist and monitor graduates to ensure that
certifications are obtained in a minimal amount of time following
graduation.
SECTION C - Obligation of the Applicant. In return for payments under
the VIOMPSP, the applicant agrees to:
1. Accept the VIOMPSP award provided by the USH under Section
B1 of this agreement.
2. Pursue a degree in a program of study that will satisfy the Hybrid
Title 38 educational requirements for Blind Rehabilitation Specialist or
Blind Rehabilitation Outpatient Specialist, at an accredited (as
determined by the USH) educational institution.
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. Submit required documentation periodically to the Scholarship
Office at times determined by VA to continue receiving the scholarship
award.
7. Complete all coursework within a maximum of four years after
enrollment for full-time students and a maximum of six years after
enrollment for part-time students.
8. Ensure that the VIOMPSP 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.
9. Sign a mobility agreement in which the participant agrees to relocate,
if necessary, at his or her own expense, to complete a service obligation
period in accordance with Sections C10 and 11 of this agreement.
10. Serve a period of obligated service. All scholarship participants in
the VIOMPSP must serve a period of obligated service as a full-time
employees in the Veterans Health Administration (VHA) in an
assignment and location determined by the USH. A participant will incur
a service obligation of three calendar years to be completed within the
first six years after the participant has completed the program for which
the scholarship was awarded and received a degree or certification
according to Section C2. No credit of time for any advanced clinical
training prior to or during scholarship training will be counted toward
satisfying the obligated service period.
11. Serve the period of obligated service by providing health services in
full-time clinical practice in the profession for which trained in an
assignment and location in VHA as determined by the USH. The
beginning date for the period of obligated service shall begin when the
USH appoints the participant as a full-time VA employee in the VHA in a
position for which the degree program prepared the participant. This is
further explained in the regulations governing the VIOMPSP.
SECTION D - Breach of VIOMPSP Award. 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
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 VIOMPSP 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 reduction of course load from full-time to part-time before completing
the course of study; fails to become credentialed in the occupation for
which the education and training was provided within one year from the
date such person becomes eligible to apply for the credentials, or fails to
meet any applicable credentialing 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; 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.
Applicant Initial
Applicant's Name:
OMB Number: 0000-0793
Estimated Burden: 15 minutes
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10-0491L
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VA FORM
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 equal to the unearned portion of
the educational assistance paid to or on behalf of the participant
determined in accordance with the following formula:
A = P((t-s)/t) in which
"A" is the amount the United States is entitled to recover;
"P" is the the amounts paid under this subchapter, to or on behalf of the
participant;
"t" is the total number of months in the participant's period of obligated
service;
"s" is the number of months of such period served by the participant in
accordance with Section 7504, 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 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 7505, Title 38, United States Code.
SECTION G - General Provisions
The USH or authorized representative must accept this agreement
before it becomes effective. The regulations and other documents
issued by the USH to implement the VIOMPSP are incorporated into
and made a part of this agreement.
I have read and understand the above agreement terms. I agree to
comply with the published statutes, regulations and policies
governing the Visual Impairment and Orientation and Mobility
Professionals Scholarship Program and to be subject to any
changes in program policy.
VA VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY PROFESSIONALS SCHOLARSHIP PROGRAM (VIOMPSP)
AGREEMENT
(continued)
Date
Date
Applicant's Name (Print)
I understand the period of obligated service for this agreement is
3 years.
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VA FORM
Applicant's Signature
Signature of Under Secretary for Health (USH), Veterans
Health Administration, or Authorized Representative
