VA Form 10-0491L VIOMPSP Agreement

OMB Number: 2900-0793
Estimated Burden: 15 minutes

VA VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY PROFESSIONALS SCHOLARSHIP PROGRAM (VIOMPSP)
AGREEMENT
INSTRUCTIONS: Do Not Make Alterations to this Document. Only
9. Ensure that the VIOMPSP program officials have access to
Use Ballpoint Pen to Complete.
educational or training institution official transcripts and other
information and documents required to assess the academic standing,
status, and progress of the scholarship recipient.
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
10. Sign a mobility agreement in which the participant agrees to relocate,
§7501-§7505.
if necessary, at his or her own expense, to complete a service obligation
period in accordance with Sections C10 and 11 of this agreement.
SECTION B - Obligation of the Under Secretary for Health (USH).
11. Serve a period of obligated service. All scholarship participants in
the VIOMPSP must serve a period of obligated service as a full-time
1. Provide the undersigned participant with a VIOMPSP award
employees in the Veterans Health Administration (VHA) in an
consisting of the payment of tuition and required fees as determined by
assignment and location determined by the USH. A participant will incur
the USH as being necessary with a maximum of $15,000 per academic
a service obligation of three calendar years to be completed within the
year for a full-time student. The maximum amount will be prorated for
first six years after the participant has completed the program for which
part-time students.
the scholarship was awarded and received a degree or certification
according to Section C2. No credit of time for any advanced clinical
2. Ensure that each participant selected for the VIOMPSP is an
training prior to or during scholarship training will be counted toward
eligible applicant, pursuing a degree in a qualifying field of education
satisfying the obligated service period.
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.
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. Scholarship recipients may not change school or program without
prior approval from the VIOMPSP Program Office.
7. Submit required documentation periodically to the Scholarship
Office at times determined by VA to continue receiving the scholarship
award.
8. 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.
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VA FORM

DEC 2019

10-0491L

12. 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 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's Name:

Applicant Initial

VA VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY PROFESSIONALS SCHOLARSHIP PROGRAM (VIOMPSP)
AGREEMENT (continued)
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:

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.

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.
VA FORM
DEC 2019

10-0491L

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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.

I understand the period of obligated service for this agreement is
3 years.

Applicant's Name (Print)

Applicant's Signature

Date

Signature of Under Secretary for Health (USH),
Veterans Health Administration, or
Authorized Representative

Date