VA Form 10-0491c HPSP/VIOMPSP Annual VA Employment Deferment Verification

OMB Number: 2900-0793
Estimated Burden: 10 minutes
Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility
Professionals Scholarship Program (VIOMPSP), & Veterans Healing Veterans Medical Access
and Education Scholarship Program (VHVMAESP)

Annual VA Employment or Deferment Verification
HPSP/VIOMPSP/VHVMAESP: Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113
PRIVACY ACT NOTICE

The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7502 (VIOMPSP), §7611 (HPSP), and §7601 (VHVMAESP) 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

VIOMPSP

VHVMAESP

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

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

Social Security Number:
Phone Number:
Email Address:

Clinical Program while in school:
Submitted for Annual Employment Verification
Attach a copy of your most recent Notification of Personnel Action
(SF-50) to this report.
Service Obligation Start Date:
My Current Position Title:
Grade and Step:

Date Degree Conferred:
Submitted for Annual Deferment Verification
Note: Submit "Education Program Completion Notice/Service Obligation
Placement" if the post graduate residency will be completed within 90 days.
Start date of the
Post Graduate Year
(PGY) residency:

Anticipated Date
to begin Service
Obligation:

What PGY has been Completed:

Total Number of Years
in the Program:

Name of VA Facility:

Name of PGY Program:

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

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

Note: Please check all applicable blocks below. If any of the blocks are not
applicable, please explain in the comments section.
I have continued full-time employment throughout my service
obligation.
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.
I have received a satisfactory performance evaluation.

Note: Please check all applicable blocks below. If any of the blocks are not
applicable, please explain in the comments section.
I have continued in my PGY Residency Program.
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 obtained a State Medical License to practice in the state of
___________________, the license number is___________________.

Comments:

Scholarship Participant's Signature

Date

Supervisor/Advisor Signature

Date

Supervisor/Advisor Title/Position

Phone

VA FORM
DEC 2018

10-0491C

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