ihs form 856-19

PUBLIC LAW 94-437 STUDENT HANDBOOK

SERVICE PAYBACK OBLIGATION

IHS-856-19

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

(Rev. 5/07)

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

PREFERRED ASSIGNMENT

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

BACKGROUND
HEALTH PROFESSION DISCIPLINE:
GRADUATION DATE:
TYPE OF DEGREE CONFERRED:
NAME OF UNIVERSITY:
DESCRIBE CLEARLY AND SPECIFICALLY THE TYPE OF WORK ASSIGNMENT YOU DESIRE TO COMPLETE YOUR SERVICE OBLIGATION:

MY SERVICE OBLIGATION PERIOD CONSISTS OF (CIRCLE ONE): 1

INDICATE

BY PRIORITY THE PREFERRED

Aberdeen, SD
Albuquerque, NM
Anchorage, AK
Bemidji, MN
Billings, MT

INDICATE

YOUR PREFERRED

IHS AREA/PROGRAM
I.H.S. Headquarters
(Rockville, MD)
Nashville, TN
Navajo, AZ
Okla City, OK

IHS HOSPITAL/CLINIC

(1)

(4)

(2)

(5)

(3)

(6)

2

3

4

years.

LOCATION FOR PLACEMENT:

Phoenix, AZ
Portland, OR
Sacramento, CA
Tucson, AZ

TO COMPLETE YOUR SERVICE OBLIGATION:

I understand that IHS officials negotiate the assignment; however, the Director, IHS has the right to make the
final decision regarding my Health Professions Section 104 Service Obligation assignment.

Applicant’s Signature

Date

Please return the completed IHS856-19 form to IHSSP, 801
Thompson Avenue, TMP Suite
450, Rockville, MD 20852.

SERVICE PAYBACK OBLIGATION

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-19

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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.