ihs form 856-13

PUBLIC LAW 94-437 STUDENT HANDBOOK

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-13

SUMMER SCHOOL REQUEST

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

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.

(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

CIRCLE ONE: Fall Winter Spring Summer

Pre-graduate

Health Professions

CIRCLE ONE: Full-time Part-time

CLEARLY AND SPECIFICALLY DEFINE THE PURPOSE OF YOUR REQUEST FOR APPROVAL TO ATTEND
SUMMER SCHOOL:

PROPOSED SESSION(S) AND COURSE(S) (Please include all courses required)
SUMMER SESSION I DATES:
COURSE NUMBER

FROM

HOURS

SUMMER SESSION II DATES:
COURSE NUMBER

TO

TITLE

FROM

TO

TITLE

HOURS

YOU MUST SUBMIT DOCUMENTATION TO SUBSTANTIATE THESE COURSE REQUIREMENTS.

FUNDING REQUESTED (Must include tuition amount for each session):
SUMMER SESSION I

SUMMER SESSION II

SUMMER SESSION III

TUITION
FEES
TOTAL
APPLICANT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE

DATE

SCHOLARSHIP COORDINATOR’S SIGNATURE

DATE

Please return the completed IHS-856-13 form to IHSSP,
801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

DATE REVIEWED (IHS use only)

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-13

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 6 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.