ihs form 856-18

PUBLIC LAW 94-437 STUDENT HANDBOOK

SERVICE PAYBACK OBLIGATION

IHS-856-18

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

(Rev. 5/07)

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

ANNUAL STATUS REPORT

See Estimated Average Burden Time
per Response on Reverse Side

APPLICANT’S NAME
STREET ADDRESS

EMAIL ADDRESS

CITY

STATE

AREA CODE AND TELEPHONE NUMBER

ZIP CODE

SOCIAL SECURITY NUMBER

HEALTH PROFESSION DISCIPLINE:
GRADUATION DATE:
TYPE OF DEGREE CONFERRED:
NAME OF UNIVERSITY:
ASSIGNMENT LOCATION:

INDIAN HEALTH SERVICE

URBAN INDIAN HEALTH PROGRAM

PRIVATE PRACTICE

638 COMPACT OR CONTRACT

NAME OF FACILITY
STREET ADDRESS
CITY

STATE

ZIP CODE

MY CURRENT POSITION TITLE:

(ATTACH TO THIS REPORT A COPY OF YOUR PERSONNEL ORDERS OR SF-50 AND A COPY OF YOUR CURRENT POSITION DESCRIPTION.)
NON-IHS EMPLOYEES MUST

ATTACH A SUMMARY WHICH IDENTIFIES THE PURPOSE, MISSION OR NATURE

OF THE EMPLOYING ORGANIZATION AND THE POPULATION SERVED BY THE ORGANIZATION.

COMMENTS:

SCHOLARSHIP RECIPIENT’S SIGNATURE

DATE

IMMEDIATE SUPERVISOR’S SIGNATURE

DATE

SUPERVISOR’S TITLE

SUPERVISOR’S TELEPHONE NUMBER

Please return the completed IHS-856-18 form to IHSSP, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

SERVICE PAYBACK OBLIGATION

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-18

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 15 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.