Form VA form 10-0491 VA form 10-0491 HPSP/VIOMPSP Academic Verification

OMB Number: 2900-XXXX
Estimated Burden: 60 minutes
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Academic Verification
1. Applicant must sign and date the "Consent for Release of Information."
2. This "Academic Verification" form is part of the application package and must be completed by the Dean/Program Director, or Administrative Chair
of applicant's program.
3. The applicant is responsible for ensuring that all documents are returned to the scholarship program office by the due date.
4. Submit completed documents to:
HPSP/VIOMPSP
Department of Veterans Affairs
1250 Poydras Street, Suite 1000
New Orleans, LA 70113

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 VA Health Professional Scholarship Program/Visual
Impairment and Orientation and Mobility Professionals Scholarship Program 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 U.S.C. Sections 7505 and 7617.
Applicant's Signature

Date Signed

Information from Applicant
HPSP

VIOMPSP

1. Name (Last, First, MI):

2. SSN:

3. Name of college or university where applicant is enrolled/accepted (Do Not Abbreviate):

4. Degree sought with this scholarship (Check one only)(VIOMPSP must be Baccalaureate or higher):
Associate

Baccalaureate

Master's

Other

Doctorate

(Specify)

6. Please list the specific degree and specialty:

5. Clinical Program:

Accreditation of Academic Program
7. Name of the organization that accredited your academic program:

Accreditation expiration date:

If program is not accredited, the applicant is not eligible for the scholarship program and this form does not need to be completed.
Representative from the program should explain the lack of accreditation to the applicant.

Admission, Enrollment and Program Completion Information
8. Applicant enrollment status (check one).
To be eligible for the scholarship award, the student must be
unconditionally admitted to the program and degree level by the
time the awards are granted. Therefore, it is critical that an
"Addendum to Application" form is submitted by the school if the
admission status changes.

Unconditionally admitted
Conditional/Pending admission (Please explain, including anticipated date of
meeting requirements for unconditional admission)
Probational admission (Please explain)

8a. Explanation:
9. What is full-time enrollment at your university/college?

Credit Hours per

Semester

10. Will the applicant be attending full-time or part-time? (HPSP must be full-time)
11. Date the applicant started or will start your
program under this scholarship program:

Full-time

Quarter
Part-time

12. Date that classes begin for the
upcoming fall semester/quarter:

13. Expected date that academic requirement(s), including all clinical rotations and/or projects will be completed:
14. Expected date degree will be conferred:
VA FORM 10-0491
3/13/12

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HPSP/VIOMPSP Academic Verification (continued)

Applicant Name:

Cumulative Grade Point Average (CGPA)
For Graduate Students
Undergraduate Cumulative Grade Point Average (CGPA) need not be identified if the student has completed 15 or more graduate hours and is
pursuing a graduate degree. If the student has not achieved 15 hours of graduate credit, identify CGPA and credit hours for all undergraduate
hours and if applicable, CGPA on credit hours for all graduate academic courses completed.
For Undergraduate Students
CGPA must be computed on all post-secondary academic courses taken within past 10 years. It should not be computed only on academic
courses accepted as satisfying the requirements of the degree for which the applicant is requesting a scholarship.
If the applicant completed academic courses more than 10 years ago, CGPA should be computed on all courses used for admission to the
program for which the scholarship is being requested.
15.

Undergraduate CGPA

based on

credit hours

Semester

Quarter

16.

Graduate CGPA

based on

credit hours

Semester

Quarter

**If there is a change in the CGPA status
after submission of this document,
forward the ADDENDUM to the
Scholarship Program immediately.

Plan of Study and Projected Costs
17. For each term please list:

Allowable Fees:

Non-allowable Fees:

Notes:

Semester/Quarter
Course Number

- Course number and title
- Credit hours for each course

(*Do not include books, supplies and equipment.)

- Total credit hours for the term
- Projected tuition cost

- Required fees for approved curriculum such as laboratory expenses
- Matriculation fees
- Graduation fees
- Library fees
- Malpractice insurance (if required for all students in the same academic program)
- Books
- Health/medical/dental/vision/life insurance
- Computers and software
- Study abroad fees
- Late charges
- Travel costs for clinical rotations
- Parking fees
- Membership dues for student societies, associations and similar expenses
- Licensure/Certification Courses/Reviews
(Annual lump-sum "Other Related Costs" payments may be used to pay for these items.)
- Tuition and fees will not be paid for courses that are being repeated.
- Specifically identify fees and whether required or optional.

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Total Tuition

Cost

Total Fees
VA FORM 10-0491
3/13/12

Tuition

Total Projected Cost
for Semester

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HPSP/VIOMPSP Academic Verification (continued)
Semester/Quarter
Course Number

Applicant Name:

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.

Tuition

Total Tuition

Cost

Fees

Total Fees

Semester/Quarter
Course Number

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Total Projected Cost
for Semester

Tuition

Total Tuition

Cost

Total Fees

Semester/Quarter
Course Number

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Tuition

Total Tuition

Cost

Total Fees
VA FORM 10-0491
3/13/12

Total Projected Cost
for Semester

Total Projected Cost
for Semester

PAGE 3 of 5

HPSP/VIOMPSP Academic Verification (continued)
Semester/Quarter
Course Number

Applicant Name:

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Tuition

Total Tuition

Cost

Total Fees

Semester/Quarter
Course Number

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Total Projected Cost
for Semester

Tuition

Total Tuition

Cost

Total Fees

Semester/Quarter
Course Number

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Tuition

Total Tuition

Cost

Total Fees
VA FORM 10-0491
3/13/12

Total Projected Cost
for Semester

Total Projected Cost
for Semester

PAGE 4 of 5

HPSP/VIOMPSP Academic Verification (continued)
Semester/Quarter
Course Number

Applicant Name:

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Tuition

Total Tuition

Cost

Total Fees

Semester/Quarter
Course Number

Start Date

End Date

Course Title

Credit Hrs

Total CH

List allowable fees for this term or that start during this term if they continue into the next term.
Fees

Total Projected Cost
for Semester

Tuition

Total Tuition

Cost

Total Fees

Total Projected Cost
for Semester

Please enclose a copy of the school's academic program curriculum.
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 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.

Certification
I understand it is my responsibility to notify the scholarship program if there are any changes in CGPA, admission status, enrollment status, plan of study,
projected costs, or program accreditation. I certify the accuracy of all information stated on this Form.
Name (Print)

Signature (Dean/Program Director/Administrative Chair of Program)

Title

Phone Number (include area code)

Date

E-mail Address

(Forward the ADDENDUM to the Scholarship Program immediately. Inaccurate data may cause both the school and the student to lose funding.)
VA FORM 10-0491
10/19/12

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