ihs form 856-10

PUBLIC LAW 94-437 STUDENT HANDBOOK

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-10

RECIPIENT’S INITIAL PROGRAM
PROGRESS REPORT

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

(Rev. 5/07)

See Estimated Average Burden Time
per Response on Reverse Side

NAME OF RECIPIENT

HEALTH DISCIPLINE

SOCIAL SECURITY NUMBER

NAME OF EDUCATIONAL INSTITUTION

ADDRESS

EMAIL ADDRESS
TELEPHONE NUMBER

TYPE OF PROGRAM

Preparatory

Pre-graduate

CIRCLE ONE: Fall Winter Spring Summer

Health Professions

CIRCLE ONE: Semester Quarter

CIRCLE ONE: Full-time Part-time
CLASS ENROLLMENT - List the courses in which you are currently enrolled if you do not have an official university printout to attach to this report.
COURSE NUMBER

TITLE

HRS.

COURSE NUMBER

TITLE

HRS.

DURING THIS REPORT PERIOD I WILL PARTICIPATE IN THE FOLLOWING SPECIAL ACTIVITIES IN MY
SCHOOL OR COMMUNITY:

DURING THIS REPORT PERIOD I HAVE ENCOUNTERED THE FOLLOWING PROBLEMS WITH MY SCHOOL,
COMMUNITY OR SCHOLARSHIP:

MAJOR ACTIVITIES WHICH WILL AFFECT ME IN THE COMING MONTHS ARE:

ADDITIONAL COMMENTS:

STUDENT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE AND TITLE

DATE

ADVISOR’S ADDRESS

ADVISOR’S TELEPHONE NO.

Please return a completed IHS-856-10 form to IHSSP,
801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

Reviewed (IHS use only):

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-10

(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.