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Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
Notice of Change and/or Annual Academic Status
(Please submit this form for any changes from the original application and annually to verify academic status.)
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.
HPSP
Annual Status/Progress Report Scholarship Participant's Name (Last, First, Middle):
VIOMPSP
Notice of Change
I am still enrolled in the school/program for which this scholarship was awarded and
do not have any changes to my original application/academic plan or previously
approved changes. (Attach a copy of your current transcript or grade report)
SSN:
Changes to my original application/academic plan
are indicated below.
Supporting documentation is required for all changes (new school fee schedule, etc...) More than one change may be selected.
Name Change
From:
To:
Address Change New Address:
From:
Completion Date Change
To:
Credit Hour Change
From:
To:
Course Change (List below)
Previously Scheduled
Semester/Quarter Start Date
Course #
New Schedule
Semester/Quarter Start Date
End Date
Course Title
Credits
Tuition
Course #
Course Title
Total
Repeat Coursework
Course #:
End Date
Credits
Tuition
Total
Course Title:
Change in Total Projected Costs
From:
To:
Academic Probation
Request for Suspension
Start:
End:
Dismissed from School Date:
Leave of Absence
Start:
End:
Change from full-time status to less then full-time status
Date:
Voluntary withdrawal from course(s) during an academic term
Date:
School/Program change (Requires prior approval. Changes are strongly discouraged.)
Date:
Date:
New School/Program:
Reason for change(s) and planned actions other than change(s) noted above:
Participant's Signature:
Date
Advisor comments:
Annual enrollment and satisfactory status/progress verified:
Advisor's Signature:
Submit to:
VA FORM 0491i
10/19/12
Advisor Disposition on proposed change(s)/actions:
Concur
Do not concur
Date
HPSP/VIOMPSP, Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113
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File Type | application/pdf |
File Modified | 2012-11-21 |
File Created | 2012-11-21 |