ihs form-856-3

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
COURSE CURRICULUM VERIFICATION
STUDENT’S NAME

REGARDING

(Check one)

See Estimated Average Burden Time
per Response on Reverse Side.

SOCIAL SECURITY NUMBER

CAREER CATEGORY

EMAIL ADDRESS

HEALTH PROFESSIONS PREGRADUATE – Section 103(b)(2)
HEALTH PROFESSIONS PREPARATORY – Section 103(b)(1)
HEALTH PROFESSIONS – Section 104

THIS FORM MUST BE COMPLETED AND THEN SIGNED BY THE APPROPRIATE COLLEGE OR UNIVERSITY OFFICIAL

This verifies that the individual referenced above has applied for admission or is enrolled at (Name of
College/University) ____________________________________________________ for the academic year
2008-2009. He/She will be enrolled in either a full-time or part-time (circle one) undergraduate curriculum
leading to a bachelor’s degree in premedicine; or a preparatory curriculum which fulfills the requirement for
admission into his/her chosen health program of ___________________________ ; or the student is enrolled in
a health professional program that is eligible for funding under this scholarship program. The individual will be
enrolled/or is anticipated to be enrolled in the following courses commencing Fall 2008.

***ATTACH CURRICULUM FOR MAJOR FROM FIRST YEAR TO COMPLETION.***
SEMESTER I OR QUARTER I
COURSE NUMBER
CREDIT HOURS

TOTAL S/Q I HOURS: _____
COURSE TITLE

SEMESTER II OR QUARTER II
COURSE NUMBER
CREDIT HOURS

TOTAL S/Q II HOURS: _____
COURSE TITLE

QUARTER III
COURSE NUMBER

ADVISOR OR COUNSELOR SIGNATURE

PRINT NAME

IHS-856-3
(Rev. 5/07)

TOTAL Q III HOURS: _____

CREDIT HOURS

COURSE TITLE

TITLE

DATE

PHONE NUMBER

EF

ATTACHMENT I (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 42 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 display 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, ATTN: PRA (0917-0006).