ihs form 856-11

PUBLIC LAW 94-437 STUDENT HANDBOOK

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-11

NOTIFICATION OF ACADEMIC PROBLEM/CHANGE

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

(Rev. 5/07)

See Estimated Average Burden Time
per Response on Reverse Side

NAME OF RECIPIENT

HEALTH DISCIPLINE

SOCIAL SECURITY NUMBER

NAME OF EDUCATIONAL INSTITUTION

ADDRESS

EMAIL ADDRESS
TELEPHONE NUMBER

TYPE OF PROGRAM

Preparatory

Pre-graduate

CIRCLE ONE: Fall Winter Spring Summer

Health Professions

CIRCLE ONE: Semester Quarter

INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU:
I AM CURRENTLY ENROLLED IN THE
MINIMUM REQUIREMENT OF 12 CREDIT
HOURS BUT AM HAVING PROBLEMS.

I HAVE BEEN PLACED ON ACADEMIC
PROBATION.

I AM A PART-TIME STUDENT CURRENTLY
ENROLLED IN AT LEAST 6 CREDIT HOURS
BUT HAVING PROBLEMS.

Previous Enrolled Credit Hours

I HAVE DROPPED COURSES WITH RECOMMENDATION AND APPROVAL OF MY
ADVISOR.

Current Enrolled Credit Hours

DESCRIPTION OF PROBLEM:

LIST BY COURSE NUMBER, TITLE, AND HOURS THE COURSES YOU ARE HAVING PROBLEMS IN:
COURSE NUMBER

TITLE

HRS.

COURSE NUMBER

TITLE

HRS.

DESCRIBE YOUR PROPOSED ACTION (i.e., obtain tutor assistance, seek no assistance and withdraw or terminate, etc.):

STUDENT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE

DATE

SCHOLARSHIP COORDINATOR’S SIGNATURE

DATE REVIEWED

BRANCH CHIEF’S SIGNATURE

DATE REVIEWED

Please return the completed IHS-856-11 form to IHSSP, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-11

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 minutes per
response including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to Indian Health Service, OPHS/DHPS/Scholarships Branch, 801 Thompson
Avenue, TMP Suite 450, Rockville, MD 20852, RE: PRA 0917-0006.