Information Collection

VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr

IC 204870 under ICR 201211-2900-008 · OMB 2900-0793.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0793 can be found here:

Documents and Forms

Document Name Document Type
Form VA form 10-0491 VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr Form
VA form 10-0491 HPSP/VIOMPSP Academic Verification 10-0491_Academic Verification.PDF To be determined Form
VA Form 10-0491a HPSP/VIOMPSP Addendum to Application 10-0491a_Addendum to Application.pdf Form
VA Form 10-0491c HPSP/VIOMPSP Annual VA employment deferment Verification 10-0491c_Annual VA Employment_Deferment Verification.pdf Form
VA Form 10-0491d HPSP/VIOMPSP Education Program Completion Notice_Service 10-0491d_Education Program Completion Notice_Service Obligation Placement.pdf Form
VA Form 10-0491e HPSP/VIOMPSP Evaluation Recommendation Form 10-0491e_Evaluation_Recommendation Form.pdf Form
VA Form 10-0491f HPSP Agreement 10-0491f_HPSP Agreement.revised.pdf Form
VA Form 10-0491g HPSP/VIOMPSP Application 10-0491g_HPSP_VIOMPSP Application.pdf Form and Instruction
VA Form 10-0491h HPSP/VIOMPSP Notice of Approaching Graduation 10-0491h_Notice of Approaching Graduation.pdf Form
VA Form 10-0491i HPSP/VIOMPSP Notice of Change and/or Annual Academic Sta 10-0491i_Notice of Change_Annual Academic Status Report.pdf Form
VA Form 10-0491j HPSP/VIOMPSP Request for Deferment for Advanced Educatio 10-0491j_Request for Deferment for Advanced Education.pdf Form
VA Form 10-0491k HPSP/VIOMPSP VA Scholarship Offer Response 10-0491k_VA Scholarship Offer Response.pdf Form
VA Form 10-0491L VIOMPSP Agreement 10-0491L_VIOMPSP Agreement.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VA Health Professional Scholarship and Visual Impairment and Orientation and Mobility Professional Scholarship Pr	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR Part 17 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA form 10-0491	HPSP/VIOMPSP Academic Verification	10-0491_Academic Verification.PDF	To be determined	Yes	No	Fillable Printable
Form	VA Form 10-0491a	HPSP/VIOMPSP Addendum to Application	10-0491a_Addendum to Application.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491c	HPSP/VIOMPSP Annual VA employment deferment Verification	10-0491c_Annual VA Employment_Deferment Verification.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491d	HPSP/VIOMPSP Education Program Completion Notice_Service Obligation Placement	10-0491d_Education Program Completion Notice_Service Obligation Placement.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491e	HPSP/VIOMPSP Evaluation Recommendation Form	10-0491e_Evaluation_Recommendation Form.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491f	HPSP Agreement	10-0491f_HPSP Agreement.revised.pdf	TBD	Yes	No	Fillable Printable
Form and Instruction	VA Form 10-0491g	HPSP/VIOMPSP Application	10-0491g_HPSP_VIOMPSP Application.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491h	HPSP/VIOMPSP Notice of Approaching Graduation	10-0491h_Notice of Approaching Graduation.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491i	HPSP/VIOMPSP Notice of Change and/or Annual Academic Status Report	10-0491i_Notice of Change_Annual Academic Status Report.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491j	HPSP/VIOMPSP Request for Deferment for Advanced Education	10-0491j_Request for Deferment for Advanced Education.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491k	HPSP/VIOMPSP VA Scholarship Offer Response	10-0491k_VA Scholarship Offer Response.pdf	TBD	Yes	No	Fillable Printable
Form	VA Form 10-0491L	VIOMPSP Agreement	10-0491L_VIOMPSP Agreement.pdf	TBD	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,500	6,500
Annual IC Time Burden (Hours)	32,689	32,689
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.