VA Form 10-0491d HPSP/VIOMPSP Education Program Completion Notice_Service

OMB Number: 2900-XXXX
Estimated Burden: 20 minutes
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Education Program Completion Notice/Service Obligation Placement
Submit within 90 days of degree conferral

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 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

Completion Notice

VIOMPSP

Service Obligation Report

SSN:

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

COMPLETION INFORMATION
(Send copy of official transcript showing the degree conferred and copy of any related licensure/certification as applicable)
Associate

Degree completed:
Date Degree Conferred:

Baccalaureate

Master's

Doctorate

Other

(Specify)

Clinical Program:

Date of Licensure/Certification:

SERVICE OBLIGATION SELECTION - Please complete if you have been selected for a position to fulfill your service obligation.
(Provide a copy of your Notification of Personnel Action (SF-50) to HPSP/VIOMPSP as soon as it is available)
Name of VA Facility (actual work site facility):

Name of parent VA Facility (as applicable.):

Address of VA Facility (actual work site facility):

Address of parent VA Facility (as applicable):

Position Title:

Occupational Code:

Grade/Step:

Appointment/Start Date:

Full-Time

Yearly Salary:

Part-Time
Hiring Official (Person at the facility who is responsible for hiring you):
Hiring Official Name:

Title/Position:

Phone Number:

Email:

SERVICE OBLIGATION UPDATE - Please complete if you have not been selected for a position to fulfill your service obligation.
(Attach a separate page if more space is needed)
Application
Date:

Facility/Position Location:

Vacancy Announcement and Title of Position:

No
Non-selection
Decision Attach copy of notification

FACILITY VACANCY I have contacted the following VA facilities and was informed that the facility is not accepting applications or has no
vacancies. (Attach a separate page if more space is needed)
Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Facility:

Contact:

Phone Number:

Signature
VA FORM 0491D
10/19/12

Date

Submit to:
HPSP/VIOMPSP Department of Veterans Affairs
1250 Poydras St., Suite 1000, New Orleans, LA 70113
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