ihs form 856-17

PUBLIC LAW 94-437 STUDENT HANDBOOK

EXTERN PROGRAM

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-17

REQUEST FOR EXTERN TRAVEL REIMBURSEMENT

(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

Travel expenses are paid according to Travel and Transportation Allowances in the Joint Travel Regulations and
Federal Travel Regulations.

EXTERN APPLICANT’S NAME

HEALTH DISCIPLINE

SOCIAL SECURITY NUMBER

NAME OF EDUCATIONAL INSTITUTION

AREA CODE AND TELEPHONE NUMBER

EMAIL ADDRESS

BELOW IS ESTIMATED EXPENSE OF PROPOSED TRAVEL
PURPOSE OF TRAVEL:
DATES OF TRAVEL:
LOCATION OF TRAVEL:

From
To

NUMBER OF AUTO MILES:
NUMBER OF DAYS:
COACH AIR FARE:
COMMENTS:

EXTERN APPLICANT’S SIGNATURE

DATE

EXTERN’S SUPERVISOR or BRANCH CHIEF SIGNATURE

DATE

Please return the completed IHS-856-17 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-856-17

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 6 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.