Application for Participation in the IHS Scholarship Program

Forms and Documents

Document Name	Status
Scholarship Application Form	Modified
Form IHS-856-6 Course Curriculum Verification Form	New
Form IHS-856-3 Faculty/Employer Evaluation Form	New
Form IHS-818 Health Professions Contract Form	New
Form IHS-817 Scholarship Program Agreement Form	New
Form IHS-816 Address Change Notice Form	New
Form IHS-815 Acknowledgment Card Form	New
Form IHS-856-24 Faculty/Advisor Evaluation Form	Modified
Form IHS-856-23 Request for Credit Validation Form	Modified
Form IHS-856-22 Change of Name or Address Form	Modified
Form IHS-856-21 Summer School Request Form	Modified
Form IHS-856-20 Request for Tutorial Assistance Form	Modified
Form IHS-856-19 Lost Stipend Payment Form	Modified
Form IHS-856-18 Request for Extern Travel Reimbursement Form	Modified
Form IHS-856-17 Extern Site Preference Request Form	Modified
Form IHS-856-16 Annual Status Report Form	Modified
Form IHS-856-15 Placement Update Form	Modified
Form IHS-856-14 Notification of Deferment Program Form	Modified
Form IHS-856-13 Notice of Impending Graduation Form	Modified
Form IHS-856-12 Preferred Placement Form	Modified
Form HS-856-11 Request for Approval of Deferment Form	Modified
Form IHS-856-10 Change of Status Form	Modified
Form IHS-856-9 Notification of Academic Problem Form	Modified
Form ihs-856-8 Recipient's Initial Program Progress Report Form	Modified
Form IHS-856-7 Verification of Acceptance or Decline of Award Form	Modified
Form IHS-856-5 Delinquent Federal Debt Form	Modified
Form IHS-856-4 Narrative Statements Form	Modified
Form IHS-856-2 Application Checklist Form	Modified
Scholarship Applicant Handbook OMB.pdf Supplementary Document	2010-05-27
Attachment 1 FRN SORN 2-6-07.pdf Supplementary Document	2010-05-27
30 Day Scholarship IC Notice 4-19-10.pdf Supplementary Document	2010-04-23
Scholarship IC 60-day FRN 7-24-09.pdf Supplementary Document	2010-04-23
Scholarship Handbook OMB.pdf Supplementary Document	2010-05-27
8-10-10_Supporting_Statement_for_IHS_Scholarship_Program_Application1 (2) (3).doc Supporting Statement A	2010-08-13

IC Document Collections

IC ID	Document Title	Status
6562	Scholarship Application Form	Modified
193119	Course Curriculum Verification Form	New
193118	Faculty/Employer Evaluation Form	New
193117	Health Professions Contract Form	New
193116	Scholarship Program Agreement Form	New
193115	Address Change Notice Form	New
193114	Acknowledgment Card Form	New
183630	Faculty/Advisor Evaluation Form	Modified
183629	Request for Credit Validation Form	Modified
183628	Change of Name or Address Form	Modified
183627	Summer School Request Form	Modified
183626	Request for Tutorial Assistance Form	Modified
183625	Lost Stipend Payment Form	Modified
183624	Request for Extern Travel Reimbursement Form	Modified
183623	Extern Site Preference Request Form	Modified
183622	Annual Status Report Form	Modified
183621	Placement Update Form	Modified
183620	Notification of Deferment Program Form	Modified
183619	Notice of Impending Graduation Form	Modified
183618	Preferred Placement Form	Modified
183617	Request for Approval of Deferment Form	Modified
183616	Change of Status Form	Modified
183615	Notification of Academic Problem Form	Modified
183614	Recipient's Initial Program Progress Report Form	Modified
183613	Verification of Acceptance or Decline of Award Form	Modified
183612	Delinquent Federal Debt Form	Modified
183611	Narrative Statements Form	Modified
183610	Faculty/Employer Evaluation	Removed
183609	Checklist	Removed
183608	Application Checklist Form	Modified

ICR Details

OMB Control No: 0917-0006	ICR Reference No: 201006-0917-001
Status: Historical Active	Previous ICR Reference No: 200801-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Application for Participation in the IHS Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/13/2010
	Date Received in OIRA: 06/02/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	36 Months From Approved	02/28/2011
Responses	17,855	0	17,330
Time Burden (Hours)	9,639	0	6,539
Cost Burden (Dollars)	0	0	0

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Abstract: Program forms collect information used to solicit, process and award scholarships, monitor academic performance and place awardees in payback sites. The data is needed to plan, manage, direct, operate and evaluate the IHSA Scholarship program.

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Authorizing Statute(s): PL: Pub.L. 94 - 437 522 Name of Law: Indian Health Care Improvement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 36714	07/24/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 20369	04/19/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 28

IC Title	Form No.	Form Name
Course Curriculum Verification	IHS-856-6	Course Curriculum Verification
Checklist
Scholarship Program Agreement	IHS-817	Scholarship Program Agreement
Application Checklist	IHS-856-2	Application Checklist
Narrative Statements	IHS-856-4	Narrative Statements
Delinquent Federal Debt	IHS-856-5	Delinquent Federal Debt
Verification of Acceptance or Decline of Award	IHS-856-7	Verification of Acceptance or Decline of Award
Recipient's Initial Program Progress Report	ihs-856-8	Recipient's Initial Program Progress Report
Notification of Academic Problem	IHS-856-9	Notification of Academic Problem
Change of Status	IHS-856-10	Change of Status
Request for Approval of Deferment	HS-856-11	Request for Approval of Deferment
Preferred Placement	IHS-856-12	Preferred Placement
Notice of Impending Graduation	IHS-856-13	Notice of Impending Graduation
Notification of Deferment Program	IHS-856-14	Notification of Deferment Program
Placement Update	IHS-856-15	Placement Update
Faculty/Employer Evaluation
Scholarship Application	NA	IHS Form 856
Annual Status Report	IHS-856-16	Annual Status Report
Health Professions Contract	IHS-818	Health Professions Contract
Faculty/Employer Evaluation	IHS-856-3	Faculty/Employer Evaluation
Extern Site Preference Request	IHS-856-17	Extern Site Preference Request
Request for Extern Travel Reimbursement	IHS-856-18	Request for Extern Travel Reimbursement
Lost Stipend Payment	IHS-856-19	Lost Stipend Payment
Request for Tutorial Assistance	IHS-856-20	Request for Tutorial Assistance
Summer School Request	IHS-856-21	Summer School Request
Change of Name or Address	IHS-856-22	Change of Name or Address
Request for Credit Validation	IHS-856-23	Request for Credit Validation
Faculty/Advisor Evaluation	IHS-856-24	Faculty-Advisor Evaluation
Acknowledgment Card	IHS-815	Acknowledgment Card
Address Change Notice	IHS-816	Address Change Notice

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	17,855	17,330	0	525	0	0
Annual Time Burden (Hours)	9,639	6,539	0	3,100	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This a reinstatement of a previously approved submission. Some of the forms were renumbered for placement in the application and student handbooks relative to the order in which they must be filled out and returned to the program. New forms were added to better address specific scholarship reporting requirements instead of E-mails and handwritten statements from scholars.

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Annual Cost to Federal Government: $80,333

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/02/2010

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