ihs form 856-12

PUBLIC LAW 94-437 STUDENT HANDBOOK

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-12

REQUEST FOR TUTORIAL ASSISTANCE

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

INDICATE ONE: Semester Quarter

CIRCLE ONE: Full-time Part-time

I AM REQUESTING TUTORIAL ASSISTANCE IN THE FOLLOWING COURSE(S):
COURSE NUMBER
TITLE

HOURS

SPECIFIC DESCRIPTION OF PROBLEMS:

DESCRIBE TUTOR ASSISTANCE NEEDED:

TUTORIAL REQUEST (Must include all tutors and describe assistance needed)
NAME(S) OF TUTOR(S)

NUMBER OF HRS. RATE PER HOUR

TUTOR(S) QUALIFICATION(S)

SUBTOTAL COST

NUMBER OF HRS. RATE PER HOUR

SUBTOTAL COST

TOTAL COST:
STUDENT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE

DATE

ADVISOR’S ADDRESS

ADVISOR’S TELEPHONE NO.
DATE REVIEWED (IHS use only)

Please return a completed IHS-856-12 form to IHSSP, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852.

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-12

(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.