ihs form 856-20

PUBLIC LAW 94-437 STUDENT HANDBOOK

DEFERMENTS

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
INDIAN HEALTH SERVICE

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

REQUEST FOR PRIOR APPROVAL OF DEFERMENT

IHS-856-20

(Rev. 5/07)

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

See Estimated Average Burden Time
per Response on Reverse Side

This document represents a prior request from you for the deferment of your service obligation incurred
under Section 338-A of the Public Health Service Act.
Name:
Address:

Email Address:
Daytime Telephone Number:
Social Security Number:
Postgraduate Clinical Program:
Program Director’s Name and Clinic Address:

Length of Program:
Date available for Service:
Name, address, and telephone number (other than your own) of a person through whom you may always
be reached:

Recipient’s Signature

Date

Please return the completed IHS-856-20 form to IHSSP, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

DEFERMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-20

(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.