VA Form 28-1904 On-The-Job Training Agreement

OMB Control No. 2900-0678
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP
(Do not write in this space)

ON-THE-JOB TRAINING AGREEMENT
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on
page 2. Use this form to outline an on-the-job training agreement. For more information, contact us
at https://www.va.gov/contact-us, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are
available at www.va.gov/vaforms. After completing the form if returning by mail, send to:
Department of Veterans Affairs, Veteran Readiness and Employment (VR&E) Intake Center,
P.O. Box 5210, Janesville, WI 53547-5210.
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.

THIS AGREEMENT, entered into as of the

day of

, 20

between Legal Name and Address of Establishment
Name
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

(herein after referred to as the Establishment) and the Department of Veterans Affairs (VA) for the purpose of
implementing the provisions of Chapter 31, Title 38, U.S. Code with reference to on-the-job training to claimants with
disabilities provides:
1. The Establishment will:
a. Identify specific job objectives for the claimant to accomplish during the program. Identify the length of time it will
take to accomplish each objective:
JOB OBJECTIVE

VA FORM
XXX XXXX

28-1904

SUPERSEDES VA FORM 28-1904, AUG 2021,
WHICH WILL NOT BE USED.

LENGTH IN MONTHS

Page 1

2. The Department of Veterans Affairs will:
a. Refer eligible claimants for on-the-job training programs as the establishment has availability.
b. Supervise the claimants progress while on-the-job training to ensure all objectives are met,
of the Federal Government and the claimants.
c. Purchase required books, tools, and equipment that are normally required to be owned by the employee and
not provided by the employer/training establishment.
d. Assume the responsibility of keeping the establishment currently informed of any, and all modifications of the
law and the VA regulations affecting the on-the-job training program for claimants with disabilities.
e. Terminate on-the-job training for any claimant whose personal conduct or lack of cooperation negatively
impacts the Training Establishment, the Department of Veterans Affairs, or the claimant.
3. Additionally:
a. Each claimant in on-the-job training under this agreement will be supervised by the establishment and
will be subject to the same rules and regulations governing the conduct of other comparable employees
of the establishment.
b. This agreement may be terminated by the establishment or the VA on (15) days' notice.
CERTIFICATION OF STATEMENT AND SIGNATURE FOR THE ESTABLISHMENT
I CERTIFY THAT I have completed this statement and that the information is true and correct to the best of my knowledge and belief.
4A. NAME AND TITLE

4C. DATE SIGNED (MM-DD-YYYY)

4B. SIGNATURE

CERTIFICATION FOR THE DEPARTMENT OF VETERANS AFFAIRS
5A. NAME AND LOCATION OF VA REGIONAL OFFICE

5B. SIGNATURE OF VETERAN READINESS AND EMPLOYMENT
REPRESENTATIVE

5C. DATE SIGNED (MM-DD-YYYY)

PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know
to be false, or for fraudulent receipt of any document you are not entitled to.
PRIVACY ACT NOTICE: The responses you submit are considered confidential (38 U.S.C. 5701). Your obligation to respond is required in order to obtain benefits. VA will
not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations
1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and
status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and
Employment Records - VA, published in the Federal Register. Information that you furnish may be utilized in computer matching programs with other Federal or State
agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in
any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid
OMB control Number. The OMB control number for this project is 2900-0678, and it expires XX/XX/20XX. Public reporting burden for this collection of information is
estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information,
including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0678 in any
correspondence. Do not send your completed VA Form 28-1904 to this email address.

VA Form 28-1904, XXX XXXX

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