VA Form 10-0491G "Application for Health Professional Scholarship Program (Hpsp) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (Viompsp)"

What Is VA Form 10-0491G?

This is a legal form that was released by the U.S. Department of Veterans Affairs on May 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 10-0491G by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 10-0491G "Application for Health Professional Scholarship Program (Hpsp) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (Viompsp)"

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OMB Number: 2900-0793
Estimated Burden: 60 minutes
APPLICATION
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER
INSTRUCTIONS: Please furnish all information in sufficient detail to enable the Department of Veterans Affairs (VA) to determine your eligibility and
ranking for selection to receive a scholarship from VA. Type or print in ink. If additional space is required, use the space in Section V.
PRELIMINARY ELIGIBILITY QUESTIONS
1. Are you currently enrolled or have you been accepted for full-time or part-time enrollment in an academic program that will
qualify you for employment in one of the fields and educational level listed in the program materials for this application cycle?
Yes
No
The academic program must be located in the United States.
2. Do you have a cumulative grade point average of 3.0 or above if some coursework is already completed?
Yes
No
3. FOR HPSP ONLY. Are you able to perform a clinical tour in an assignment or location determined by VA while enrolled in
Yes
No
the course of education for which the scholarship is provided? This will require temporary relocation at your expense if there is
not a VA facility near your educational program or if your education program does not have an affiliation agreement with the
N/A for
nearby VA facility. Check with your advisor before answering this question.
VIOMPSP
4. Are you able to complete the required full-time VA employment obligation after graduation and required licensure/
certification? This will require relocation at your expense if there is not a suitable vacancy or you are not selected for
Yes
No
employment at a VA facility nearby.
5. Are you a citizen of the United States?
Yes
No
6. Are you delinquent on payment of a federal debt? This includes delinquent taxes, audit disallowances, guaranteed or direct
student loans, Federal Housing Administration (FHA) or VA mortgages, and other miscellaneous administrative debts.
Yes
No
Delinquent is defined as 31 days past due on a scheduled payment.
7. Do you currently owe a service obligation to any other entity to perform service after you complete the course of study for
Yes
No
which this scholarship is being provided?
If you answered "No" to any of questions 1-5
or
answered "Yes" to questions 6 or 7,
you are NOT eligible for this scholarship program and you should not submit an application.
SUMMARY OF THE COMPLETE APPLICATION PACKAGE
The following items constitute a complete application package.
It is your responsibility to ensure that your application package is complete, accurate, and submitted by the deadline date.
Incomplete applications will not be reviewed.
1. HPSP_VIOMPSP Application (VA Form 10-0491g)
2. Academic Verification Form (VA Form 10-0491)
3. Evaluation & Recommendation Forms (VA Form 10-0491e)
3a. From academic program where you will be or where you are currently enrolled (Required)
3b. From a person who has known you for a minimum of two years (Required)
3c. From your VA supervisor or equivalent person if the supervisor is no longer available
(Required if you were employed by Department of Veterans Affairs in the last three years)
4. Academic Transcript (Unofficial transcript acceptable)
5. Resumé
(Include prior education, professional licenses/registration/certifications and detailed descriptions of volunteer and work experiences
especially that which is healthcare related. Resumés should not exceed 5 pages and must be at least 11 point font. Resumés that are
longer in length or written in smaller font will not be reviewed.)
6. Declaration for Federal Employment (OF 306)
10-0491G
VA FORM
PAGE 1 of 7
MAY 2017
OMB Number: 2900-0793
Estimated Burden: 60 minutes
APPLICATION
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER
INSTRUCTIONS: Please furnish all information in sufficient detail to enable the Department of Veterans Affairs (VA) to determine your eligibility and
ranking for selection to receive a scholarship from VA. Type or print in ink. If additional space is required, use the space in Section V.
PRELIMINARY ELIGIBILITY QUESTIONS
1. Are you currently enrolled or have you been accepted for full-time or part-time enrollment in an academic program that will
qualify you for employment in one of the fields and educational level listed in the program materials for this application cycle?
Yes
No
The academic program must be located in the United States.
2. Do you have a cumulative grade point average of 3.0 or above if some coursework is already completed?
Yes
No
3. FOR HPSP ONLY. Are you able to perform a clinical tour in an assignment or location determined by VA while enrolled in
Yes
No
the course of education for which the scholarship is provided? This will require temporary relocation at your expense if there is
not a VA facility near your educational program or if your education program does not have an affiliation agreement with the
N/A for
nearby VA facility. Check with your advisor before answering this question.
VIOMPSP
4. Are you able to complete the required full-time VA employment obligation after graduation and required licensure/
certification? This will require relocation at your expense if there is not a suitable vacancy or you are not selected for
Yes
No
employment at a VA facility nearby.
5. Are you a citizen of the United States?
Yes
No
6. Are you delinquent on payment of a federal debt? This includes delinquent taxes, audit disallowances, guaranteed or direct
student loans, Federal Housing Administration (FHA) or VA mortgages, and other miscellaneous administrative debts.
Yes
No
Delinquent is defined as 31 days past due on a scheduled payment.
7. Do you currently owe a service obligation to any other entity to perform service after you complete the course of study for
Yes
No
which this scholarship is being provided?
If you answered "No" to any of questions 1-5
or
answered "Yes" to questions 6 or 7,
you are NOT eligible for this scholarship program and you should not submit an application.
SUMMARY OF THE COMPLETE APPLICATION PACKAGE
The following items constitute a complete application package.
It is your responsibility to ensure that your application package is complete, accurate, and submitted by the deadline date.
Incomplete applications will not be reviewed.
1. HPSP_VIOMPSP Application (VA Form 10-0491g)
2. Academic Verification Form (VA Form 10-0491)
3. Evaluation & Recommendation Forms (VA Form 10-0491e)
3a. From academic program where you will be or where you are currently enrolled (Required)
3b. From a person who has known you for a minimum of two years (Required)
3c. From your VA supervisor or equivalent person if the supervisor is no longer available
(Required if you were employed by Department of Veterans Affairs in the last three years)
4. Academic Transcript (Unofficial transcript acceptable)
5. Resumé
(Include prior education, professional licenses/registration/certifications and detailed descriptions of volunteer and work experiences
especially that which is healthcare related. Resumés should not exceed 5 pages and must be at least 11 point font. Resumés that are
longer in length or written in smaller font will not be reviewed.)
6. Declaration for Federal Employment (OF 306)
10-0491G
VA FORM
PAGE 1 of 7
MAY 2017
Application for Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
SECTION I - Scholarship Program Information
1. Scholarship Program
2. Length of Award
(More than 12 months of
3. Clinical Program:
scholarship support is considered a multi-year
award)
1 year
2 or more years
HPSP
VIOMPSP
Associate (HPSP only)
Baccalaureate
Other
(Specify)
4. Degree sought via
HPSP/VIOMPSP
(Check one only)
Major field of study
Master's
Doctorate
SECTION II - Applicant Information
5a. Name
5b. Other Names Used
(For example: maiden name, nickname, etc.)
(Last, First, Middle)
6. Present Address
(Include Street Address, City, State, and ZIP Code)
7a. Primary Phone Number
(include area code)
7b. Alternate Phone Number
(include area code)
9a. Primary Email Address
9b. Alternate Email Address
10. Are you a U.S. Citizen?
8. Social Security Number
Yes
No
If yes, date you completed your obligation :
11. Are you a previous HPSP/VIOMPSP recipient?
Yes
No
Name, permanent address, and telephone number of person through whom you can be located
(e.g., parent, sibling, friend, etc...):
12. Name
13. Relationship
(Last, First, Middle)
14. Address
(Include Street Address, City, State, and ZIP Code)
15. Phone Number
(include area code)
16. Email Address
Associate
Baccalaureate
Other
(Specify)
17. Highest degree obtained
(Check only highest
completed)
Major field of Study
Master's
Doctorate
18. Do you or will you have a service obligation (commitment of service) that will conflict with a service obligation incurred
Yes
No
under the scholarship program for which you are currently applying?
(If Yes, explain in Section V.)
19. Have you served in the military including active duty and reserves?
Yes (Provide information below)
No
From
To
Branch of Service/Military Occupation
Type of Discharge
Honorable
Other
(Explain in Section V)
Honorable
Other
(Explain in Section V)
Honorable
Other
(Explain in Section V)
10-0491G
VA FORM
PAGE 2 of 7
MAY 2017
Application for HPSP/VIOMPSP
(continued)
20. Were you ever convicted by a court-martial?
Yes
No
(If so, describe in Section V.)
21a. Are you a current or previous Department of Veterans Affairs employee?
No
Current
Previous
21b. If VA employed, Start Date of last VA employment
21c. End Date of last VA employment
21d. Location
21e. Occupational Series Code
21f. Job Title
Yes
Described in Resumé
22. Have you ever been employed in a healthcare occupation?
(If not described in Resumé,
describe in Section V.)
No
Described in Section V
SECTION III - Education Program Information
23. Name of college or university where you are enrolled/accepted.
(Do Not Abbreviate)
24. Name of college/department/school
25. Phone Number
(include area code)
26. Address
27a. Academic Advisor
(Include Street Address, City, State, and ZIP Code)
27b. Advisor's Phone Number
27c. Advisor's Email
a. Traditional
programs
b. Non-Traditional (Off campus) programs consisting
(On campus)
c. Mixed Traditional
of curricula in off-campus settings (e.g., distance
28. Type Program
consisting of curricula offered in
and Non-Traditional
learning via the internet).
a campus setting.
29. Start date of academic program that will
30. End date of academic program that will be
be supported by the scholarship program
supported by the scholarship program
31. NOTE: The HPSP requires that scholarship participants perform clinical tours in assignments or locations determined by VA while enrolled in the
course of education for which the scholarship is provided. This may require temporary relocation at your expense if there is not a VA facility near
your educational program, or if your education program does not have an affiliation agreement with the VA facility nearest you. Check with your
advisor before answering this question. The VIOMPSP does not require clinical tours.
Are you willing and able to meet this scholarship program requirement?
Yes
No
SECTION IV - Additional Applicant Information
32. Awards
(academic/performance):
33. Professional Activities:
10-0491G
VA FORM
PAGE 3 of 7
MAY 2017
Application for HPSP/VIOMPSP
(continued)
34. Organizational Membership(s)/Office(s) Held:
Please respond to the questions 35A-C within the space provided. (Use only 10pt or 12pt font) (250 word limit per section)
35a. Why do you want to participate in the scholarship program for which you are applying? (250 word limit)
35b. What are your short-range (less than five years) and long-range (between five and ten years) career goals? (250 word limit)
10-0491G
VA FORM
PAGE 4 of 7
MAY 2017
Application for HPSP/VIOMPSP
(continued)
35c. How will your personal characteristics, experiences and career goals help meet the health needs of Veterans? (250 word limit)
36. Have any of the following ever been, or are they in the process of being -- either on a voluntary or involuntary basis -- denied, revoked, suspended,
reduced, limited, placed on probation, not renewed, withdrawn, or relinquished while under investigation or for disciplinary reasons? (Each "yes"
response requires a complete explanation in Section V.)
a. Professional Registration/License in any State?
Yes
No
b. Participation in Medicare/Medicaid Program, or been convicted of and or investigated for making and or using false,
fictitious, or fraudulent statements, representations, writings or documents, regarding a material fact in connection with the
Yes
No
delivery of, or payment for health care benefits, items or services that would be in violation of the Criminal False Claims
Act?
c. Clinical Privileges?
Yes
No
d. Federal Drug Enforcement Agency Registration?
Yes
No
e. Certification?
Yes
No
37. Have you ever been involved in administrative, or judicial proceedings in which professional malpractice on your part has been
Yes
No
alleged? (If yes, please explain in Section V.)
38. Within the last 5 years, have you been discharged from any position for any reason? (If yes, please explain in Section V.)
Yes
No
39. Within the last 5 years have you resigned or retired from a position after being notified you would be disciplined or discharged, or
Yes
No
after questions about your clinical competence were raised? (If yes, please explain in Section V.)
40. Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives
offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but does
Yes
No
not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment of two
years of less.) (If yes, please explain in Section V.)
10-0491G
VA FORM
PAGE 5 of 7
MAY 2017