ihs form 856-7

ATTACHMENT V
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
JOB EXPERIENCE (MPH Students Only) [Optional]
NAME OF APPLICANT

SOCIAL SECURITY NUMBER

See Estimated Average Burden Time
per Response on Reverse Side.

CURRENT CAREER CATEGORY

EMAIL ADDRESS

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

HEALTH RELATED JOBS OR VOLUNTEER EXPERIENCE (BEGIN WITH MOST RECENT WORK EXPERIENCE)
A. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

STATUS
PAID
VOLUNTEER

Yes
Yes

No
No

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

B. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

C. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

D. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

E. EXACT TITLE OF YOUR POSITION

DATES EMPLOYED (Give Month & Year)
FROM:
TO:

Average # of Hrs.
Worked per Week

DESCRIPTION OF WORK (Briefly describe your specific duties, responsibilities and accomplishments in the position)

IHS-856-7
(Rev. 5/07)

EF

ATTACHMENT V (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 50 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).