10-0003k
Employee Incentive Scholarship Program (EISP) Application
VA Form 10-0003k is the U.S. Department of Veterans Affairs Employee Incentive Scholarship Program (EISP) Application, for employees enrolled in or formally accepted to an education or training program. The directions say it is to be used only by VA employees who are already enrolled in or have been accepted to accredited programs to receive education or training in health care occupations for which recruitment or retention is difficult. It is a VA employee form, not a Veterans benefit application.
The form is three pages. Page 1 holds the directions and the Privacy Act notice. Section 1 covers identification and educational history, Section 2 the EISP enrollment information and estimated program costs, and Section 3 the authentication signed by the employee and by the facility Director or designee. VA's page lists VA Form 10-0003K-2, the EISP Agreement, as the related form.
You can fill out the PDF free in your browser on this page and download the result without an account.
Whether you are a previous participant, facility name, location and number, name, Social Security number, home and work phones, full-time or part-time VA employment status, occupational series, title and assignment codes, current job title and grade, and your rating official's name and work phone.
Your highest degree obtained and the total semester hours accumulated to date. The form says to convert quarter hours to semester hours by multiplying the number of quarter hours by two-thirds.
The degree sought, program start and estimated completion dates, a traditional or non-traditional program, a program description, the educational institution, any VISN supported program, the semester hours required and the attendance schedule.
Estimated tuition by type of institution, other reimbursable program costs, total program costs, the average cost per semester hour and costs by fiscal year. The form says the Item 31 total must equal Item 28, Total Program Costs.
Whether you have a mentor, with the mentor's name and title, and whether special working condition arrangements are needed to support your EISP attendance, with a description and whether they are in place yet.
A consent letting your school release enrollment status and academic standing to VA, the eligibility certification, your printed name, signature and date, and the Director or designee's recommendation, signature and date.
Page 1 explains who uses the application, who reviews it and where the signed agreement goes.
The form says to print or type all entries in Sections 1 and 2, checking only one box where it says to check one only.
Item 22 says to attach a copy of your Letter of Acceptance, or a copy of an official transcript.
Print your name, sign and date the authentication. The Director or designee signs each approved application.
Send the application to the EISP Program Coordinator. Section 3 says to forward a copy to HRRO when completed.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The application goes to the EISP Program Coordinator, who forwards it to the Selection Committee. The authenticated application and the original agreement then go to HRRO for final acceptance and signature.
The directions say the Program Coordinator provides a copy of the agreement to the scholarship recipient, places the original in the Official Personnel Folder and places copies in local files.
The directions say any questions may be referred to HRRO at (504) 565-4900.
The PDF footer reads VA FORM JUN 2010 10-0003K, matching the June 2010 revision date on VA's page.
The directions on page 1 say who fills it in and where it goes next.
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The directions say it is to be used only by VA employees who are already enrolled in or have been accepted to accredited programs in health care occupations for which recruitment or retention is difficult.
Yes. VA's page lists VA Form 10-0003K-2, Employee Incentive Scholarship Program (EISP) Agreement, as a related form. The directions say the original agreement signed by the student goes to HRRO with the authenticated application.
Item 22 says to attach a copy of your Letter of Acceptance, or a copy of an official transcript, from the educational institution where you are accepted or enrolled.
The employee prints a name, signs and dates Section 3. The facility Director or designee signs each approved application to recommend the applicant.
The form says to multiply the number of quarter hours by two-thirds.
Section 3 says the authorization is voluntary and may be revoked at any time, but that revoking it after the award ends the scholarship and makes the employee liable for damages under Section 7675, Title 38, United States Code.
The directions say any questions may be referred to HRRO at (504) 565-4900.
