ihs form 856-16

PUBLIC LAW 94-437 STUDENT HANDBOOK

EXTERN PROGRAM

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-16

EXTERN SITE PREFERENCE REQUEST

(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

I am applying to:

Civil Service

COSTEP Program

APPLICANT’S NAME
STREET ADDRESS
CITY

STATE

AREA CODE AND TELEPHONE NUMBER

ZIP CODE

EMAIL ADDRESS

HEALTH PROFESSION CURRENTLY ENROLLED IN:
PROJECTED GRADUATION DATE:

CURRENT GPA:

NAME OF UNIVERSITY:
DO YOU PLAN TO CHANGE YOUR MAJOR OR SCHOOL? EXPLAIN:

DATES AVAILABLE FOR EXTERN ASSIGNMENT:

From

To

DESCRIBE CLEARLY AND SPECIFICALLY THE TYPE OF EXTERN ASSIGNMENT YOU DESIRE:

EXTERNSHIP SITE PREFERENCE
INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR EXTERNSHIP:
Aberdeen, SD
Albuquerque, NM
Anchorage, AK
Bemidji, MN
Billings, MT

I.H.S. Headquarters
(Rockville, MD)
Nashville, TN
Navajo, AZ
Okla City, OK

Phoenix, AZ
Portland, OR
Sacramento, CA
Tucson, AZ

INDICATE YOUR PREFERRED IHS HOSPITAL/CLINIC FOR EXTERNSHIP:
(1)

(2)

(3)

(4)

COMMENTS:

Extern Applicant’s Signature

Date

Please return the completed IHS856-16 form to the SCHOLARSHIP COORDINATOR FOR YOUR IHS AREA (see
pages B-02 through B-04 for listing).

EXTERN PROGRAM

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-16

(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.