10-0491e
Evaluation & Recommendation Form—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
VA Form 10-0491E is the Department of Veterans Affairs Evaluation & Recommendation Form for the Health Professional Scholarship Program (HPSP) and the Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP). An evaluator, such as academic faculty or an employer, rates a scholarship applicant on it. The form says the governing law provides that, in evaluating and selecting individuals for scholarships, consideration will be given to faculty or employer recommendations.
The PDF has two pages: the Privacy Act and burden notices, a consent for release of information in the applicant's words, items on the evaluator's relationship to the applicant, three rated questions with comment boxes, and a certification with the evaluator's printed name, title, signature and date. VA Form 10-0491G lists these evaluation forms as part of a complete scholarship application package.
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The applicant's authorization for the school and prior employers to release information to VA. It says the authorization is voluntary and may be revoked at any time, and what revoking after an award may mean under 38 U.S.C. Sections 7505 and 7617.
The scholarship program (HPSP, HPSP (Vet Center) or VIOMSP, as printed), the relationship to the applicant, the length of time known, and whether the evaluator is academic faculty, a non-VA employer, a VA employer or other.
Ratings from 1 (Poor) to 5 (Excellent), with the form's interpretation of each. The form says the evaluation is meant to ensure fairness, consistency and alignment with the scholarship's mission.
Ratings and comments on the applicant's academic performance or workplace achievements, interpersonal skills and communication, and overall potential in providing care for those who have served in the military and their families, caregivers and survivors.
Two statements, on not being related to the applicant and on having provided all relevant information, then the evaluator's printed name, title or position, signature and date (MM/DD/YYYY).
Check HPSP, HPSP (Vet Center) or VIOMSP in item 1.
Specify the relationship to the applicant and the length of time known, and check the evaluator type in item 4.
Choose a rating for each of the three questions. The form says evaluators are strongly encouraged to provide comments with examples to support the selected rating.
Check both certification statements on page 2, print your name and title or position, sign and enter the date.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
VA Form 10-0491G lists Evaluation & Recommendation Forms (VA Form 10-0491e) as item 3 of a complete application package, and says incomplete applications will not be reviewed.
VA Form 10-0491E prints no mailing address of its own. VA Form 10-0491G prints the address for the completed application.
The burden statement says not to send the completed VA Form 10-0491e to [email protected], the address for comments on the burden estimate.
The PDF footer reads VA FORM SEP 2026 10-0491e, matching the September 2026 revision date on VA's page. It carries OMB Control No. 2900-0793, which expires 09/30/2029, and an estimated burden of 30 minutes.
10-0491g
118 fields, 7 pages
10-0491
481 fields, 7 pages
10-0491k
35 fields, 1 page
10-0491f
13 fields, 4 pages
10-0491L
12 fields, 3 pages
The evaluator fills in most of the form. VA Form 10-0491G says which evaluations an application package holds.
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It is the Evaluation & Recommendation Form an evaluator completes for an applicant to the HPSP or VIOMPSP scholarship programs.
VA Form 10-0491G lists one from the academic program (required), one from a person who has known the applicant for a minimum of two years (required), and one from a VA supervisor or equivalent if the applicant was employed by VA in the last three years.
The certification on page 2 has the evaluator certify that they are not related to the applicant by blood or marriage.
1 (Poor), 2 (Fair), 3 (Average), 4 (Above Average) and 5 (Excellent), with a comment box under each of the three questions.
The consent says the authorization is voluntary and may be revoked at any time, but that revoking it after the award may lead to the scholarship award being terminated and liability for damages under 38 U.S.C. Sections 7505 and 7617.
