ihs form 856-14

PUBLIC LAW 94-437 STUDENT HANDBOOK

BREACH & DEFAULT / MONITORING & PLACEMENT

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

IHS-856-14

(Rev. 5/07)

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

PLACEMENT UPDATE

See Estimated Average Burden Time
per Response on Reverse Side

SUBMITTED ON:

Date/Year

Placement Officer
IHS Scholarship Branch
801 Thompson Avenue - TMP Suite 450
Rockville, Maryland 20852
Name:
Address:
Email Address:
Telephone Number:
Social Security Number:
Health Professions Discipline:
Graduation Date:
Type of Degree:
Name of University:
OF 612 – Optional Application for Federal Employment or Commissioned Corps Application (PHS
Form 50), Health Professions Scholarship Program Service Obligation Preferred Assignment Form
(Form IHS-856-19) sent to IHSSP Placement Officer:
POSITIONS APPLIED FOR (Rejection Letters Attached):
Vacancy Announcement/Title:
Vacancy Announcement/Title:
Vacancy Announcement/Title:

Signature (Do Not Print)

Please return the completed IHS856-14 form to IHSSP, 801
Thompson Avenue, TMP Suite
450, Rockville, MD 20852.

BREACH & DEFAULT / MONITORING & PLACEMENT

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-14

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 11 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.