Supporting Statement
IHS Scholarship Program Application
A. JUSTIFICATION
l. Circumstances making information collection necessary:
The Indian Health Service (IHS) is requesting (reinstatement), with change, of previously approved information collection activity; 0917-0006, "IHS Scholarship Program Application” for which approval has expired.
This information is collected under the "Indian Health Care Improvement Act", Public Law 94-437, as amended. The Act authorizes the conduct of the Health Professions Preparatory Scholarship Program for Indians, the Health Professions Pre-graduate Scholarship Program, and the Health Professions Scholarship Program to train the health professional personnel necessary to staff IHS health programs and other health programs serving the American Indian and Alaska Native (AI/AN) people in occupational categories and geographic locations where there are health manpower shortages (Attachment 1).
2. Purpose and use of the information collection:
The information collection is used to plan, manage, direct, operate and evaluate the agency's scholarship programs. The forms contained in the booklet and handbook discussed below are used to solicit and process program applications (Attachment 2).
IHS Scholarship Program Application Information Instruction Booklet
This booklet provides an overview of the scholarship programs, eligibility requirements, selection criteria and ranking procedures for recipients and it contains the instructions and forms that need to be completed and submitted by all program applicants. The forms are discussed in the order as provided in the booklet.
Form IHS-856, “Application for Participation in the Indian Health Service Scholarship Program”. The form IHS-856 is the initial application form and must be completed by each applicant. The information provided from this form is used to establish a demographic and educational profile of each applicant and includes; type of scholarship, health career, date of graduation, tribal affiliation, full-time/part-time status, etc. This information is entered into IHS's scholarship management information system and provides a base for the rating/ranking and eligibility procedures used to make an award. Added “”Email Address” on page 5; this page was added for more contact information on the applicant. Also added, “on page 8, 7b. “IMPORTANT: Indicate the month and year. Be sure to darken in the month and year of your expected completion of the required coursework or graduation date.”, this statement was added to further indicate what is required on this form, in order for the applicant understand that the graduation date is necessary for it to be complete.
Form IHS-856-3, “Course Curriculum Verification”. This form identifies and verifies the school, course number(s), course title(s) and number of credit hours in which the applicant is enrolled. Added “In the “REGARDING” section, a field for an email address was added. Also added, at the bottom of the form is two fields for the advisor or counselor to print name and phone number.”
Form IHS-856-4, “Faculty/Employer Evaluation”. This form collects faculty and/or employer evaluation of the applicant. The information is used as part of the applicant rating process. Added , in the “REGARDING” section, a field for an email address was added.
Form IHS-856-5, “Reasons for Requesting Scholarship”. This form requests applicant to provide a written narrative to three statements. Responses are used as part of the applicant rating process. Added , a field for an email address was added.
Form IHS-856-6, “Delinquent Federal Debt Form”. This form is used by applicant to identify and certify any delinquent Federal debt. Added , a field for an email address was added.
Form IHS-856-7, “Job Experience (MPH Students Only) [Optional]”. This optional form is completed only by applicants applying for a Masters in Public Health and is used to indicate their health related jobs or volunteer experience in health programs. Added , a field for an email address was added.
Form IHS-856-8, “Verification of Acceptance or Decline of Award”. This form is completed by an applicant after they are notified that they have been awarded a scholarship. Before funds can be obligated and a “Letter of Award” is issued, the successful applicant must complete this required form to accept or decline the offer of an IHS Scholarship. Added , a field for an email address was added.
Form IHS 856-2, “Application Checklist”. Applicants complete and sign this form to indicate that their scholarship application complete. It is considered part of the application package and must be submitted with the package. Change wording on number 5, from “Documents for Indian Eligibility” to “Documentation for American Indian/Alaskan Native Eligibility”. Removed the “CONTINUING” column, the checklist will be utilized only by “NEW” applicants.
Form IHS 815, “Acknowledgement of Receipt of Application”. Applicants complete this form with their addresses. This is their receipt that application was received.
Form IHS 816, “Address Change Notice”. Funded applicants complete this form only when there is a change of address. This is a “fold and mail” form.
Form IHS 817, “Health Professions Preparatory and Pregraduate Education Scholarship Program Agreement - School Year 2008-2009. This is signed by Preparatory (Section 103) and Pregraduate (Section 103P) applicants to indicate agreement to stated terms and conditions as participants. There is no service payback obligation in this agreement.
Form IHS 818, “Indian Health Scholarship Program Contract, School Year 2008-2009, Health Professions”. Health Professions (Section 104) applicants sign this contract thereby agreeing to a period of obligated service equal to one year for each year of funding. Terms and conditions are detailed on this form.
B. Indian Health Service Scholarship Program Student Handbook
Scholarship recipients each receive a copy of the “IHS Scholarship Program Student Handbook”, which contains forms used for monitoring, placement, and to request other program benefits. The handbook instructions have been revised and updated.
Form IHS-856-9, “Lost Stipend Checks”. Scholarship recipients use this form to initiate tracing action on an electric funds transfer (student stipend) that was not received. The form number “Form D-02" has been changed to “IHS-856-9".
Form IHS-856-10, “Recipient's Enrollment and Initial Program Progress Report”. This form is used to identify the courses in which enrolled and verify that the student is enrolled in either a full-time or part-time course load for the semester/quarter/trimester. The form number “Form F-02" has been changed to “IHS-856-10". The title of the form has been changed from “Recipient’s Enrollment and Initial Program Progress Report” to “Recipient’s Initial Program Progress Report”A field for a email address has been added.
Form IHS-856-11, “Notification of Academic Problem/Change”. This form is completed by students having academic problem(s), who are placed on academic probation, or who fall below the minimum full-time or part-time credit hours. The notice alerts IHS scholarship program staff of students experiencing academic difficulty and provides an opportunity to offer appropriate intervention to assist these students to succeed. The form number “Form F-04" has been changed to “IHS-856-11". A field for a email address has been added.
Form IHS-856-12, “Request for Tutorial Assistance”. This form is used by students requesting tutorial assistance. The form number “Form G-02" has been changed to “IHS-856-12". A field for a email address has been added.
Form IHS-856-13, “Summer School Request”. The form is used by students requesting to attend summer school. The form identifies the summer session dates, class courses and the funding being requested. The form number “Form G-04" has been changed to “IHS-856-13". Added at the top of form “A Summer School Request must be received in the IHS Scholarship Office by April 22 of the academic year in order for an applicant to be eligible for Summer School”, to insure that summer school requests are submitted in a timely matter. Added a field requesting an email address. Added “please include all courses required” after “PROPOSED SESSSION(S) AND COURSE(S)”.
Form IHS-856-14, “Placement Update”. This form is used to monitor the placement process of graduating Health Professions Scholarship Program (Section 104) recipients to fulfill their mandatory payback service obligation. The form number “Form H-07" has been changed to “IHS-856-14". Added a line requesting an email address. Changed “(Form K-04)” to “(Form IHS-856-19)”.
Form IHS-856-15, “Notice of Impending Graduation”. This form that is used by the Health Professions Scholarship Program (Section 104) recipients who will be graduating from their degree program. This form is used to monitor the student's progress towards placement in a position that will fulfill the student's mandatory payback service obligation..The form number “Form H-08" has been changed to “IHS-856-15". Added a line requesting an email address
Form IHS-856-16, “Extern Site Preference Request”. This form is completed by those students requesting temporary employment within the IHS under the Agency's Scholarship Extern Program and provides an opportunity for the student to request their preferred work site. The form number “Form J-04" has been changed to “IHS-856-16". Added a field requesting an email address
Form IHS-856-17, “Request for Extern Travel Reimbursement”. This form is completed by students requesting travel reimbursement for one round trip to the extern site. The form number “Form J-05" has been changed to “IHS-856-17". Added a field requesting an email address and “area code and phone number”.
Form IHS-856-18, “Health Professions Scholarship Program Annual Status Report”. This form is used by the Health Professions Scholarship Program (Section 104) recipients who have graduated from their degree program and are at a service payback site. This form verifies that the recipient is serving at an approved payback site and fulfilling their service obligation. The form number “Form K-03" has been changed to “IHS-856-18". Added a field requesting an email address.
Form IHS-856-19, “Health Professions Scholarship Program Service Obligation Preferred Assignment”. This form is completed by graduating Health Professions Scholarship Program (Section 104) recipients and is used to identify their preferred payback sites. The IHS Scholarship Branch staff use this information to aide in the placement process of these graduates. The form number “Form K-04" has been changed to “IHS-856-19". Added a field requesting an email address.
Form IHS-856-20, “Request for Prior Approval of Deferment”. This form is completed by graduating scholarship recipients requesting deferment of their service obligation to attend postgraduate training. The form number “Form L-03" has been changed to “IHS-856-20". Added a field requesting an email address.
3. Use of information technology and burden reduction:
Automated information technology is utilized, as appropriate, for processing the IHS Scholarship applications. In many instances, written responses are required to answer form questions.
4. Efforts to identify duplication and use of similar information:
No similar information is collected from this population.
5. Impact on small businesses or other small entities:
An IHS scholarship applicant may send the Faculty/Employer Evaluation Form (Form IHS-856-4), to a current or former employer who is a small business or other small entity. It is estimated that this form will require less than hour to complete. The items of information requested are the minimum required to permit IHS staff to make an informed decision concerning the suitability of the IHS scholarship applicant seeking an award.
6. Consequences of collecting the information less frequently:
A scholarship application for this program must be completed prior to the beginning of each academic school year. If this information collection were to be conducted less frequently, it would not be possible to determine eligibility or to track the scholastic progress of the scholarship recipients.
7. Special circumstances relating to the guidelines of 5 cfr 1320.5:
The collection of information will be consistent with 5 CFR 1320.5.
8. Comments in response to the federal register notice and efforts to consult outside agency:
No Comments were received in response to the August 10, 2007, Federal Register notice (72 FR 45054). (Attachment 4). Two IHS scholarship applicants and recipients (respondents) provided feedback. Neither expressed any difficulty in completing the forms, or understanding the instructions for their completion. In addition, the forms and instructions reflect feedback from the members of the IHS Scholarships Program Standing Committee:
Leah Exendine 8 Lida Circle Carson City, NV 89706 775-882-1007 |
Verna Wood Graves P.O. Box 542 Red Lake, MN 56601 218-751-9439 |
George Blue Spruce, Jr. 18190 N. Timber Ridge Dr. Surprise, AZ 85374 623-975-4104 |
Evangelyn Dotomain 3925 Tudor Centre Drive Anchorage, AK 99508 907-729-1913 |
Roselinda Allison P.O. Box 9020 Window Rock, AZ 86515 928-871-1358 |
Mona Celli 650 Capital Mall, 3rd Floor Sacramento, CA 09814 916-9930-3981, ext 325 |
9. Explanation of any payment or gift to respondents:
No payment is provided to respondents for providing the requested information. Successful applicants may receive a benefit in the form of an IHS Scholarship.
10. Assurance of confidentiality provided to respondents:
Data gathered on this application form constitute a system of records as defined under the Privacy Act of 1974. The systems notice for the IHS Scholarship Programs is 09-17-0002 IHS Scholarship Programs, HHS/IHS/OHP (Attachment 3). This information was published in the Federal Register on February 6, 2007 (72 FR 5446). The information collected through use of the IHS Scholarship Program application, as well as handling and storage of this information, will be in compliance with the Privacy Act. A Privacy Act Notice, which describes the authority for collecting the information, the purposes for which the information is collected, routine use disclosures which may be made of the information collected and the necessity of reporting to receive scholarship award consideration, is contained in the "Indian Health Service Scholarship Program Student Handbook”, and the “Applicant Information Instruction Booklet for the IHS Scholarship Programs”.
11. Justification for sensitive questions:
There are no questions on the application form which are considered to be sensitive.
12. Estimate of hour burden including annualized hourly cost:
Annual Burden Hours
Data collection instrument(s) |
Number of respondents |
Responses per respondent |
Total annual response |
Burden Hour per Response |
Annual Burden Hours |
Scholarship Application (856) |
1500 |
1 |
1500 |
1 |
1500 |
Checklist (856-2) |
1500 |
1 |
1500 |
8/60 |
200 |
Course Verification (856-3) |
1500 |
1 |
1500 |
42/60 |
1050 |
Faculty/Employer Evaluation (856-4) |
1500 |
2 |
3000 |
50/60 |
2500 |
Justification (856-5) |
1500 |
1 |
1500 |
45/60 |
1125 |
Federal Debt (856-6) |
1500 |
1 |
1500 |
8/60 |
200 |
MPH (856-7) |
25 |
1 |
25 |
50/60 |
21 |
Accept/Decline (856-8) |
650 |
1 |
650 |
8/60 |
87 |
Receipt of Application (815) |
1500 |
1 |
1500 |
2/60 |
50 |
Address Change Notice (816) |
25 |
1 |
25 |
1/60 |
25 |
Scholarship ProgramAgreement(817) |
850 |
1 |
850 |
3/60 |
43 |
Health Professions Contract (818) |
650 |
1 |
850 |
3/60 |
33 |
Stipend Check (856-9) |
100 |
1 |
100 |
8/60 |
13 |
Enrollment (856-10) |
1300 |
1 |
1300 |
8/60 |
173 |
Academic Problem/Change (856-11) |
50 |
1 |
50 |
8/60 |
7 |
Request Assistance (856-12) |
217 |
1 |
217 |
8/60 |
29 |
Request Summer School (856-13) |
193 |
1 |
193 |
6/60 |
19 |
Placement (856-14) |
250 |
1 |
250 |
11/60 |
46 |
Notice of Graduation (856-15) |
250 |
1 |
250 |
10/60 |
42 |
Site Preference (856-16) |
150 |
1 |
150 |
8/60 |
20 |
Request Travel Reimb (856-17) |
150 |
1 |
150 |
6/60 |
15 |
Status Report (856-18) |
250 |
1 |
250 |
15/60 |
63 |
Preferred Assignment (856-19) |
200 |
1 |
200 |
45/60 |
150 |
Request for Deferment (856-20) |
20 |
1 |
20 |
8/60 |
3 |
Grand Total |
17,330 |
--- |
--- |
--- |
6,539 |
*For ease of understanding, burden hours per response are also provided in minutes.
13. Estimate of other total annual cost burden to respondents or record keepers:
There is no direct cost to respondents.
14. Annualized cost to the federal government:
The estimated cost to the Federal Government is $90,000. It is based upon $65,000 for application booklet and forms printing and application review and $25,000 for computer processing and maintenance.
15. Explanation for program changes or adjustments:
The program change increase in the burden hours is due to the ever increasing number of individuals applying for the IHS scholarship programs.
16. Plans for tabulations and publication and project time schedule:
There are no plans for the tabulation, statistical analysis and publication of information collected.
17. Reason(s) display of OMB expiration date is inappropriate:
OMB information will be displayed on information collection forms accordingly.
18. Exceptions to certification for paperwork reduction act submissions:
None.
B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS
This information collection activity will not employ sampling to select respondents (IHS Scholarship Program applicants).
ATTACHMENTS
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 1
P.L. 94-437, "The Indian Health Care Improvement Act” as amended
42 CFR Sections 36.320, 36.330 and 36.370
Attachment 2:
Application for Participation in: The Indian Health Service Scholarship Programs.
Form IHS-856 with copy of previous form highlighting revised section(s).
B. Applicant Information Instruction Booklet for the IHS Scholarship Programs.
Forms IHS-856-2 to 8, IHS-815 and IHS-816
C. Indian Health Scholarship Program Contract and Agreement
Form IHS-817 and IHS 818
D. Indian Health Service Scholarship Program Student Handbook.
Forms IHS-856-9 to 20
Attachment 3
Privacy Act systems notice, “09-17-0002 IHS Scholarship Programs, HHS/IHS/OHP”
Attachment 4
Request for Public Comment in Federal Register Notice - 60 day
Agency Response to Public Comment: No comments received.
Attachment 5
Draft - Request for Public Comment in Federal Register Notice - 30 day
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 1
P.L. 94-437, "The Indian Health Care Improvement Act” as amended
42 CFR Sections 36.320, 36.330 and 36.370
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 2:
Application for Participation in the Indian Health Service Scholarship Programs.
Form IHS-856 with copy of previous form highlighting revised section(s).
B. Applicant Information Instruction Booklet for the IHS Scholarship Programs.
Forms IHS-856-2 to 8, IHS-815 and IHS-816
C. Indian Health Scholarship Program Contract and Agreement
Form IHS-817
Form IHS-818
D. Indian Health Service Scholarship Program Student Handbook.
Forms IHS-856-9-20
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 3
Privacy Act systems notice, “09-17-0002 IHS Scholarship Programs, HHS/IHS/OHP”
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 4
Request for Public Comment in Federal Register Notice - 60 day
Agency Response to Public Comment: No comments received.
IHS SCHOLARSHIP PROGRAM APPLICATION
Attachment 5
Draft - Request for Public Comment in Federal Register Notice - 30 day
| File Type | application/octet-stream |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |