10-264E Evaluation and Recommendation

OMB Control No. 2900-XXXX
Estimated Burden: 50 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

EVALUATION & RECOMMENDATION FORM

Return this completed form to: RCSSP, Readjustment Counseling Service (10RCS), Department of Veterans Affairs, 810 Vermont Ave. NW, Washington, DC 20420
Scholarship Program:

RCSSP

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

The applicant identified above is applying to receive a Department of Veterans Affairs scholarship. The information on this form is requested pursuant to 38 CFR
sections 17.545 through 17.553. These governing documents provide that, in evaluating and selecting individuals for scholarships, consideration will be given to faculty
or employer recommendations.
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct
or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this
form will average 50 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) in order for VA to
determine the applicant's eligibility to receive a 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 the applicant's 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 process the applicant's request for a scholarship. If you give VA a social security number, VA will use it to obtain information
relevant to determining whether to grant a scholarship, and to administer the applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.

CONSENT FOR RELEASE OF INFORMATION

CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my enrollment status and academic
standing, including grade point average, both now and while I am participating in the Readjustment Counseling Service Scholarship Program (RCSSP) as well as the
plan of study and projected costs. I understand that this authorization is voluntary, and that I may revoke this consent at any time. However, I further understand that if I
voluntarily revoke this authorization after the award of the scholarship, my scholarship award may be terminated and I may be liable for the damages in accordance with
provisions of 38 CFR sections 17.545 through 17.553. I authorize my prior employers and other individuals who receive this form to release the requested information to
the Department of Veterans Affairs.

Date Signed (MM/DD/YYYY)

Applicant's Signature
Evaluation/Recommendation Type:

Academic Faculty

Employer (non-VA)

VA Employer

Relationship to applicant:

Other

Length of time known:

EVALUATION
(Comments are strongly encouraged and will assist in the scoring of the applicant's application)
1. How do you rate the educational/work achievement of this applicant? (Please provide written comments)
5 - Outstanding

4 - Above Average

3 - Average

2 - Below Average

1 - Poor

Comments:

2. How do you rate the applicant's relationships with other people?
Consider such things as ability to work and get along with others. (Please provide written comments)
5 - Outstanding

4 - Above Average

3 - Average

2 - Below Average

1 - Poor

Comments:

3. Based on this applicant's personal, emotional, ethical attributes, how do you rate his/her over-all potential for providing clinical services to our nation's
Veteran population? (Please provide written comments)
5 - Outstanding

4 - Above Average

3 - Average

2 - Below Average

1 - Poor

Comments:

Scholarship Recommendation:
Conflict of Interest Statement:

Recommended

Not Recommended

I certify that I am not related to the applicant by blood or marriage.

Initials:

Institution/Organization (Name & Address)
Evaluator (Print)
Title/Position

Evaluator (Signature)
Date (MM/DD/YYYY)

If you have any questions, please contact the Department of Veterans Affairs, Readjustment Counseling Service Clinical Team at
VHARCSClinicalOversight@va.gov.
VA FORM
NOV 2021

10-264E

10RCS

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