Scholarship Handbook

Scholarship Handbook OMB.pdf

Application for Participation in the IHS Scholarship Program

Scholarship Handbook

OMB: 0917-0006

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INDIAN HEALTH SERVICE

Student Handbook
Your Health Career Starts Here

Career Opportunities Start Here
Congratulations on receiving your Indian Health Service (IHS) Scholarship.
You’ve taken the first steps toward your future by furthering your education,
envisioning your health career and setting goals. The IHS Scholarship Program
will help you realize the future you envision for yourself.
The first IHS scholarship was awarded in 1977. In the last 17 years alone, more
than $200 million have been awarded to American Indian and Alaska Native
students to help them reach their career goals and dreams, while helping IHS
to fulfill its mission: to raise the physical, mental, social and spiritual health of
American Indians and Alaska Natives to the highest level. You will be part of
that mission by traveling a path that brings you opportunity, adventure and a
sense of personal fulfillment, working in an American Indian/Alaska Native
community where you’re really needed – perhaps your own community.
This booklet contains information on the IHS Scholarship Programs, the
requirements and benefits of the programs, continuation support, key forms
and a convenient checklist to help you stay on track. Please write or call the
IHS Scholarship Program or your Area Coordinator if you have any questions
about the scholarship or the reporting requirements.
On behalf of the Indian Health Service, thank you for your interest in serving
your fellow American Indian and Alaska Native people.

[Robert’s signature]
Robert E. Pittman, R.Ph., M.P.H.
Rear Admiral, USPHS
Assistant Surgeon General
Director, Division of Health Professions Support

TABLE OF CONTENTS
Introduction

Section A

Section B

Section C

Purpose of the Scholarship Programs

Overview of Scholarship Programs

Health Professions Preparatory Scholarship Program

Health Professions Pre-Graduate Scholarship Program

Health Professions Scholarship Program

Overview of Student Handbook

Requirements

Overview of Scholarship Requirements

Academic Requirements

Reporting Requirements

Initial Program Progress Report

Transcripts

Notification of Academic Problem or Change

Change of Status

Address for Correspondence

Taxes

Credit Validation

Benefits

Tuition and Required Fees

Books, Laboratory Expenses, Other Necessary
Education Expenses and Travel

Living Expenses Stipend

Overview

Lost Stipend

Summer School

Tutorial Assistance

Acceptance of Other Federal Benefits

Other Public Health Service Benefits

Veterans Benefits

Benefits from State, Local and Other Federal Programs

Suspension of Benefits

Continuation Support

Notice to all Continuation Students

TABLE OF CONTENTS

Section D

Section E

Health Professions Preparatory Scholarship Program

Health Professions Pre-Graduate Scholarship Program

Health Professions Scholarship Program

Payback/Service Obligation for Health Professions
Scholarship Program Recipients

Requirements of Health Professions Scholarship Program Graduates

Application/Placement Process

Monitoring the Placement Process

Documentation Requirements

Deferments

Post-Graduate Training

Specialties and Approval

Breach and Default of Contract

Failure to Complete Academic Training

Failure to Begin or Complete the Service Obligation or 33
Meet the Terms and Conditions of Deferment

Section F

Extern Program

Overview

Eligibility

Civil Service

Commissioned Corps

Application

Benefits

Salary

Travel

Housing

Section G

Contact Information – All pertinent contact information can be found in this
section. For specific names and email, visit www.scholarship.ihs.gov.
Overview

Area Office Scholarship Coordinators, Indian Health Service Area Offices
and Special Scholarship Offices

IHS Discipline Representative

IHS Scholarship Branch Chief

Section H
Section I

Section J

Section K

IHS Scholarship Award Program Compliance Analyst

Default Waiver Coordinators

Scholarship Applications/Award Analyst

Scholarship Program Extern Coordinator

IHS Division of Grants Operations

IHS Grants Scholarship Coordinator Officer

IHS Scholarship Grants Management Specialist

Health Professions Scholarship Program Branch

Sample Contracts

Checklist

Reporting

Continuation

Additional Forms

Forms

Lost Stipend Checks/Direct Deposit (Form IHS-856-9)

Initial Program Progress Report (Form IHS-856-10)

Notification of Academic Problem or Change (Form IHS-856-11)

Request for Tutorial Assistance (Form IHS-856-12)

Summer School Request (Form IHS-856-13)

Placement Update (Form IHS-856-14)

Notice of Impending Graduation (Form IHS-856-15)

Extern Site Preference Request (Form IHS-856-16)

Request for Extern Travel Reimbursement (Form IHS-856-17)

Annual Status Report (Form IHS-856-18)

Preferred Assignment (Form IHS-856-19)

Request for Prior Approval of Deferment (Form IHS-856-20)

Federal Income Tax Withholding (Form W-4)

Disclaimers

Discrimination Prohibited

Privacy Act Notice

Reporting Fraud and Abuse

Introduction
Purpose of the Scholarship
Programs

Health Professions Pre-Graduate
Scholarship Program

In September of 1976, the Congress and the president of the
United States enacted the Indian Health Care Improvement Act
(Public Law 94-437), which declared that “it is the policy of
this Nation, in fulfillment of its special responsibilities and legal
obligation to the American Indian people, to meet the national
goal of providing the highest possible health status to Indians
and to provide existing Indian health services with all resources
necessary to effect that policy.”

The Pre-Graduate Scholarship Program provides financial
support for American Indian and Alaska Native (federally or
state-recognized) students only to enroll in courses leading to
a bachelor’s degree in specific pre-professional areas, such as
pre-medicine, pre-dentistry and others as needed by Indian
health programs.

To help accomplish this goal, the Act and subsequent amendments of 1980, 1988, 1992 and 1996 authorize the Indian
Health Service (IHS) to conduct three interrelated scholarship
programs, for American Indian and Alaska Native students,
to train the health professionals necessary to staff IHS health
programs and other health programs serving the Indian people.

Overview of Scholarship Programs
Health Professions Preparatory
Scholarship Program
The Preparatory Scholarship Program provides financial
assistance for American Indian and Alaska Native (federally or
state-recognized) students only to enroll in courses (compensatory or preparatory) in preparation for entry to health
professional schools, such as medical, nursing, pharmacy and
others as needed. Compensatory courses are those required
to improve science, mathematics or other basic skills and
knowledge. Preparatory courses are pre-professional studies
required in order to qualify for admission to a health professions program.
Health Professions Preparatory Scholarship Program support
is paid for 10 months each academic year with re-application
required for each year of continuation, and is available for up
to two academic years full-time or 4 academic years part-time.
Support covers costs of compensatory and pre-professional
education that enables the student to qualify for enrollment or
reenrollment in a health professions school, i.e., freshman and
sophomore years of study leading to a bachelor’s degree in a
priority health profession, or the four years of undergraduate
study required for entry into graduate professional school.

Pre-Graduate scholarship support is paid for 10 months each
academic year, with re-application required for each year of
continuation, for up to four academic years full-time or eight
academic years part-time, for studies leading to enrollment in
an accredited professional school.

Health Professions Scholarship Program
The Health Professions Scholarship Program is for American
Indian and Alaska Native students enrolled in health professions
and allied health professions programs. Students incur service
obligations and payback requirements on acceptance of funding
from this program. Priority is given to graduate students and
junior- and senior- level students unless otherwise specified.
Health Professions Scholarships are awarded for a one year
period (12 months of support), with re-application required for
each year of continuation. Stipends are paid for the 12-month
period beginning each year from August 1 through July 31 for
health and allied health professional education up to four years
full-time or up to eight years part-time.

Overview of Student Handbook
This Student Handbook is designed to enhance your knowledge
and understanding of the reporting requirements you must
fulfill to maintain scholarship support and your benefits.
Used properly, this handbook curtails time-consuming
correspondence and costly telephone calls, and gives you
immediate access to information for situations not previously
encountered. It contains all the necessary IHS forms you need,
and also contains the addresses of IHS offices you can contact if
problems arise.

Section A: Requirements
Overview of Scholarship
Requirements
The IHS Scholarship Program requirements are listed in this
section. Please read this section carefully and make notes of
the conditions pertaining to your scholarship award. Please
note the address and telephone number for your IHS Area
Coordinator listed in the contact information section of this
handbook. The names of specific coordinators can be found
at www.scholarship.ihs.gov. They will assist you with any
academic or potential compliance problems that may develop
while you are attending school.
Immediately notify the Area Scholarship Coordinator of
technical problems, travel, payments, etc. Many situations can
be resolved before escalating to a serious level.
Please maintain all pertinent information with the scholarship
and grants staff as soon as you anticipate a change.
All changes should be sent in writing to the
Scholarship Program.

Section A: Requirements
It is your responsibility to uphold your status as a
recipient with the guidelines explained in the following
pages. These requirements include progress reports of
your academic standing, course load and curriculum. For
recipients of the Health Professions Scholarship Program,
you must complete an application for placement and serve
at a qualifying site to satisfy your payback obligation.

Academic Requirements
Health Professions Preparatory Scholarship Program and
Health Professions Pre-Graduate Scholarship Program
Requirements
It is IHS policy that Health Professions Preparatory Scholarship
Program and Health Professions Pre-Graduate Program recipients
must maintain good academic standing each semester/quarter
and must be full-time students with a minimum of 12 credit
hours (unless approved for part-time status as outlined below).

Health Professions Requirements
Health Professions Scholarship Program recipients must maintain
a 2.0 cumulative grade point average (GPA) each semester/
quarter in core courses and must be a full-time student with
a minimum of 12 credit hours (unless approved for part-time
status). Health Professions Scholarship Program recipients must
also be enrolled in an approved/accredited school for a health
professions degree.
Students are not eligible for continuation if they have not
maintained a 2.0 cumulative GPA in core courses.
Part-time students for the three scholarship programs must
also maintain a 2.0 cumulative GPA in core courses and must
take at least six to 11 credit hours each semester/quarter. You
must be approved for part-time status at the time of scholarship
award. You cannot change from part-time status to full-time
status, or vice versa, in the same academic year. Please refer
to the Notification of Problem or Change under the Reporting
Requirements portion of this handbook.

Reporting Requirements
All of the following reports and documents must be sent to
the IHS Scholarship Program, 801 Thompson Avenue, Suite
120, Rockville, MD, 20852.
If you fail to submit these reports as required, you will be
ineligible for continuation of scholarship support and your
scholarship payments will be discontinued.

Initial Program Progress Report
Within 30 days from the beginning of each semester or
quarter, you must submit an Initial Program Progress
Report (Form IHS-856-10) to the IHS Scholarship Program,
signed by your school advisor or the registrar’s office verifying
that you are enrolled in a full-time or part-time course load
for the semester/quarter. You must also submit a course
curriculum outline, approved by your advisor, for your chosen
health program.

Transcripts
Within 30 days from the end of each academic period, i.e.,
semester, quarter or summer session, you must submit an
official transcript. Official transcript means the institutional
seal and/or the signature of the registrar must be present.
Copies of official transcripts are not acceptable. If an official
transcript will not be available within 30 days, you must submit
a copy of your official grade report or documentation indicating

Section A: Requirements
the grades received in each class, signed by each instructor and
your advisor. When your transcripts do become available, you
must have an official copy sent directly to the IHS Scholarship
Program. If an official transcript is not submitted, all benefits
will be suspended.

Notification of Academic Problem or
Change
If at any time during the semester/quarter you experience
academic problems or are advised to reduce the number of
credit hours in which you are enrolled below the minimum
of 12 hours for a full-time student or at least six hours for
part-time students, you must submit a Notification of
Academic Problem or Change (Form IHS-856-11) to the Area
Scholarship Coordinator and the IHS Scholarship Program. If you
are enrolled in at least 12 credit hours for full-time or six hours
for part-time and are doing satisfactorily in all classes (at least
a “C” or better), do not submit this form unless you want to
alert your Area Scholarship Coordinator to a special problem you
are experiencing or to request assistance, e.g., tutorial service
or approval to drop a course.

Change of Status
Change of Academic Status
Academic Probation
If placed on academic probation, you must notify your Area
Scholarship Coordinator and the IHS Scholarship Program
immediately. Notification will alert your coordinator that you
need special assistance such as tutorial services or reductions of
course load. The Area Scholarship Coordinator will advise you on
alternatives that may help you.

Withdrawal from School
If you are considering voluntarily withdrawing from school for
any reason (personal or medical), you should inform your Area
Scholarship Coordinator and the IHS School Program prior to
actually dropping your classes. Your coordinator may be able to
advise you of alternative courses of action that will allow you to
continue in the scholarship program. If you do withdraw from
school, the IHS Scholarship Program must be notified immediately in order to stop your stipend checks. If you fail to notify
the IHS Scholarship Program and you continue to cash stipend
checks, you will be liable for the return of all funds to which
you were not entitled. If you have been awarded a Health
Professions Scholarship Program you will also be liable for
repayment of all Scholarship Program funds paid to the school
on your behalf.

Dismissal from School
You must notify the Area Scholarship Coordinator and the IHS
Scholarship Program immediately if you are dismissed from
school. If you fail to notify the IHS and you continue to cash
stipend checks, you will be liable for the return of all funds
to which you were not entitled. If you have been awarded a
Health Professions Scholarship Program you will also be liable
for repayment of all Scholarship Program funds paid to the
school on your behalf.

School Transfer Request
At least 30 days prior to the time of transfer to a new school
from the school you are currently attending, you must request
approval from the IHS Scholarship Program for the change.
state clearly the reason for the transfer. The school transfer
request is for scholarship continuation students only. It is not
available for new students receiving the IHS Scholarship for the
first time.

You may request a transfer of schools during the school year for
only two reasons:
» To change from a school with a non-accredited program in
your health discipline to a school with an accredited program.
» To change from a school that does not offer courses required
for your health professions degree to a school offering the
necessary courses.
Personal and/or family hardships, which may necessitate school
transfer, will be considered on an individual basis.
You must submit with your request a school acceptance letter,
which specifies entry into a specific health professions program
and a course curriculum. Also, you must submit documentation to verify the number of hours and courses earned and the
number of hours and courses transferable from your current
school to the school you are requesting to attend. You will be
notified of IHS’ approval or disapproval of the request.
If you change schools without prior IHS approval, your
scholarship award will be discontinued.

Change of Health Discipline
Change of health disciplines must be requested in writing to the
IHS Scholarship Program and authorization received before you
apply for continuation of your scholarship. The health discipline
to which you are changing must be one of the IHS priority
categories listed for the new scholarship cycle.
Additionally, Faculty and Employer Evaluation and Reasons
for Requesting Scholarship forms must be completed and
submitted with your continuation application. Submit
documentation to verify the number of hours earned and
transferable from your current program into the new health
discipline program you are requesting. If change of discipline
requires school transfer, change of graduation date or program
change, consult the appropriate sections of this handbook for
additional requirements.
You can not change from the approved IHS Scholarship Program
health discipline during the school year. If you make an
unapproved change, your scholarship payments will be discontinued and you are subject to being placed in default status.

Change in Graduation Date
Any time a change occurs in your expected graduation date,
you must notify the IHS Scholarship Program and your Area
Scholarship Coordinator immediately in writing. You must
submit documentation (signed by a school official) supporting
the proposed change.

Program Change
Changes from one type of scholarship to another can occur only
at the end of the academic funding year. Changes cannot be
made during the academic year. If you are funded as a Health
Professions Preparatory Program student and complete your
preparatory courses after mid-year or any part of the year, and
begin your health profession courses during mid-year or any
part of the year, you will be funded for the entire year under
the agreement for which you were originally awarded.
You must provide supportive documentation when requesting
a change from the Health Professions Preparatory Scholarship
Program to a Health Professions Scholarship Program (letter
of acceptance for your chosen health professional program) or
from the Health Professions Scholarship Program to a Health
Professions Preparatory Scholarship Program (verification that
you are enrolled in preparatory courses and a copy of your
proposed curriculum). All requests must be submitted to the IHS
Scholarship Program.

Leave of Absence Request
If for any reason, you cannot continue with your courses/
classes during a semester/quarter, you must submit a written
request for leave of absence to the IHS Scholarship Program.
The leave of absence request may be for one semester or a full
academic year.
Once reviewed and approved, the approval letter will keep
you in good standing with the IHS Scholarship Program and
allow you to file a continuation application when you are ready
to re-enter school. The maximum leave of absence is limited
to two consecutive years and must be requested annually. Any
need for further leave of absence will be reviewed on a caseby-case basis.
As long as the IHS Scholarship Program is kept informed of your
academic status, you will remain in the active-non-pay status.

Name Change
Legal documentation must be received by the IHS Scholarship
Program before a student’s record is changed to reflect a
new name.

Section A: Requirements
Address for Correspondence

Taxes

You are required to obtain a post office box to serve as your
correspondence address for the period of the scholarship
award. The IHS Scholarship Program will provide payment
for a post office box or banking account fee, included in the
August stipend. This address should not change to prevent
delay or loss of correspondence. However, if your address
does change, you must promptly notify us. Address changes
received after the 10th of each month will not take effect until
the following month.

IHS Scholarship funds are subject to federal income tax, and
possibly state and local taxes. IHS withholds only federal
income taxes from your stipend checks. Please inquire in your
state about any state tax liability on your award. For instructions concerning allowances, exemptions and filing status, refer
to the W-4 form for the current year in the Forms section.

Previous scholarship recipients have encountered delays up to
eight weeks in receiving their correspondence when addresses
have been changed and the IHS Scholarship Program has not
been notified.

The IHS Scholarship Program will verify your status upon receipt
of a written request for the release of pertinent information
from your file to a credit card company, bank, department store,
etc. Your request must include your signature and Social Security
number. We cannot respond to credit inquiries by telephone.

Credit Validation

Section B: Benefits

Section B: Benefits
The level of IHS Scholarship Program benefits is dependent
on the availability of funds appropriated each fiscal year by
the Congress of the United States, and therefore is subject to
change each year.

» Tutorial costs. A maximum of $400 for full-time or
$200 for part-time for the academic year is paid directly
to the student, who must specifically request tutorial
services. Payment is subject to approval of the Scholarship
Branch Chief.

Tuition and Required Fees

IHS will not pay the following items:

IHS makes direct payment to your school for tuition and
required fees for the school year. Summer school is excluded
unless specifically requested and approved in advance. IHS
will officially notify the school of your participation in the IHS
Scholarship Program. Until the school receives billing instructions, this notification of award authorizes your school to bill IHS
directly for your tuition and required fees during the first week
of October.

» School bookstore invoices or books/dental/medical equipment (unless certain dental/medical equipment is rented
from the school).

IHS pays for tuition and fees (calculated by the educational
institution) directly applicable to your approved curriculum
and program. Payment will not be made for tuition and fees
unrelated to the approved program, for membership dues
for student societies, associations and similar expenses, or
for school terms that begin prior to the academic year for
which the scholarship is awarded. The amount awarded
cannot be increased above what the school submitted for
your degree program.

» Health insurance. The educational institution will accept
documentation from your Tribe or Indian Health Service
facility that you are eligible for health care and/or contract
health care from/through our Indian health programs. If you
find that the availability of health care services is inconvenient, you will be responsible for a separate health insurance
policy, group or individual, while in school.
» Additional travel expenses incurred over the lump sum
amount of $300.

IHS will only pay for repeat course work previously paid for by
IHS if the course is taken during summer school, not during the
regular school year.

Books, Laboratory Expenses,
Other Necessary Education
Expenses and Travel
IHS will pay for the following:
» Tuition costs and mandatory fees. Any mandatory fees, such
as lab fees and health unit fee, are paid if they’re included
on the school’s invoice. The school should submit all invoices
to the IHS Division of Grants Operations.
» Books, laboratory expenses and other education expenses.
These are paid in advance in a lump sum to the student for
the school year in the August stipend.
» $300 to offset travel expenses to and from school for the
year, paid in advance to the student in the August stipend.

Section B: Benefits
Living Expenses Stipend
Overview
The estimated stipend amount for student living expenses,
including room and board, will be mailed at the end of each
month. This amount is pro-rated for part-time students. Each
scholarship recipient will receive an award letter specifying the
total dollar amount for the award.
Health Preparatory and Health Professions Pre-Graduate
Scholarship Program recipients will receive a stipend for only
the academic period covered by their awards: August 1 to May
31. The first stipend checks will be electronically transmitted
(EFT) via direct deposit to their bank accounts at the end of the
month of August. Stipends for the months of June and July will
be paid only to those students who have requested to attend
summer sessions and have been approved in advance to do so.
Health Professions Scholarship Program recipients will be given
a stipend for the 12-month period beginning August 1 through
July 31. The first stipend checks will be electronically transmitted via direct deposit to their bank accounts or mailed from
the Treasury Department at the end of the month of August.
For part-time students this amount is prorated based on the
number of credit hours taken during the academic year.
NOTE: All participants are required to have direct deposit
for method of payment.
Although funds may be identified as salary, they are stipend
payments. To protect yourself, you should not write checks on
your account until you have received notice from your bank that
the EFT has occurred. If your EFT is delayed and checks drawn on
your account are not honored due to insufficient funds, the IHS
Scholarship Program cannot pay any penalties your bank may
impose for returned checks.

Lost Stipend
The Treasury Department will transfer funds during the last three
days of the month. If you do not receive your stipend, you must
immediately notify the Grants Scholarship Coordinator, Division
of Grants after the seventh day of the subsequent month so that
the Treasury Department can be authorized to issue a replacement EFT to cover the amount you did not receive. Submit the
Lost Stipend form (Form IHS-856-9). For example, if you do
not receive your stipend at the end of November, you may
submit the Lost Stipend form on December 7.
You may find that other students at your school received their
EFT while you have not. The reason may be that the funds for

students at the same school are not necessarily transferred
from the Treasury Department at the same time.
Changes in direct deposit information are the primary
reason for non-receipt of EFT.

Summer School
Students may need to take summer courses to graduate or
complete course requirements necessary for graduation within
the four year maximum time period for full-time students
(eight year maximum time for part-time students) or for earlier
acceptance into a health professions program.
A Summer School Request (Form IHS-856-13) must be
received by the IHS Scholarship Program by April 22 of the
academic year to be able to attend that summer.
The Summer School Request must be completed and signed by
your school advisor with an attached curriculum for your major.
Documentation may be a curriculum listing for your program or
a statement from your advisor. Your academic program must
require these courses. Summer school can also be used to
make up failed required courses for which IHS will pay fees and
tuition. Summer school is not approved for optional courses not
related to your academic program. Documentation of summer
school tuition and fees must be submitted with your summer
school request form.
Summer school costs are paid only if you have received prior
approval from the IHS Scholarship Branch Chief. The IHS Scholarship Program will pay up to $700 for full-time students or $350
for part-time students for tuition and fees as billed by your
school. There is no limitation on credit hours. The student must
pay costs over these amounts. No additional funds are available
for books or other miscellaneous expenses. For those students
who are in allied health programs that are year-long, you will
not be limited to the $700 or $350; however, summer school
requests should be submitted to ensure the yearly budget will
cover the tuition and fees.
Stipends will be extended into June and July for Health Preparatory and Pre-Graduate students who are approved for summer
school. Health Professions students already receive their stipends
for 12 months, from August to July.
Transcripts for summer school are due to the IHS Scholarship Program as soon as they are available at the end of
the semester term. Please ensure these are ordered.

students who have been in school for the academic year
(August 1 through July 31). The funds are paid directly to the
students on a reimbursed basis as part of the monthly stipend
check upon approval of the tutorial request. The student is
responsible for paying the tutor.

Acceptance of Other Federal
Benefits
If you are currently receiving scholarship funding from other
federal agency sources, you should inform the awarding agency
if you are selected to receive an IHS Scholarship. This is done to
eliminate duplicate payment of tuition and other educational
expenses. Additionally, the awarding agency might have
prohibitions against duplicate awards.

Other Public Health Service Benefits
If you are receiving scholarship funds under the National Health
Service Corps Scholarship Program (Section 751 of the Act) or
the Scholarship Program for First-Year Students of Exceptional
Financial Need (Section 758 of the Act), you are not eligible
to participate in the IHS Scholarship Program during the school
year(s) for which these scholarships were awarded.

Veterans Benefits

Tutorial Assistance
IHS wants to assist you in getting the maximum benefit from
your education and this scholarship. If you have difficulty with
one or more courses, you may participate in special classes or
arrange for tutorial assistance to correct the difficulty and to
improve your academic performance.
To request tutorial assistance, submit a completed copy of the
Request for Tutorial Assistance (Form IHS-856-12). Your
school advisor must sign this form. Send this to the IHS Scholarship Program, Attention: Scholarship Application/Award Analyst.
You are encouraged to use tutorial services to improve
your grades even if they are satisfactory and/or to address
weaknesses in other courses, such as in English or math, which
may affect your overall academic performance.

You may continue to receive educational benefits from the
Veterans Administration (G. Bill) along with the IHS Scholarship Program funds since the VA benefits were earned by prior
active duty in a uniformed service.

Benefits from State, Local and Other Federal
Programs
If you owe an obligation for professional practice to a state or
other entity under an agreement made before applying for IHS
scholarship funding, you are not eligible for an award unless
the state or entity submits to the Secretary a written statement
which says:
» There is no potential conflict in fulfilling your service obligation to the state or entity and the IHS Scholarship Program.
» The Scholarship Program service obligation will be served
before the service obligation for professional practice owed
to the state or entity.

The IHS Scholarship Program will pay up to $400 for tutorial
assistance to full-time students and up to $200 to part-time

Section B: Benefits
Suspension of Benefits
THE IHS SCHOLARSHIP PROGRAM WILL SUSPEND THE
PAYMENT OF ALL BENEFITS FOR THE PERIOD OF TIME THAT:
» The school and the IHS Scholarship Program have
approved a participant’s leave of absence for medical
or personal reasons; or
» A recipient’s graduation is delayed for personal reasons
or by a requirement to repeat course work for which the
IHS Scholarship Program has previously paid the tuition
and provided stipend support.
The participant is required to notify the IHS Scholarship Program
when leave of absence or repeated course work is expected.
Documentation is required by the IHS Scholarship Program on
an as-needed basis.
Benefits suspended will not resume until the IHS Scholarship
Program is notified by the school that the participant has
returned to the course of study for which the scholarship was
awarded and only if funds are available to continue support.
If repeated course work does not delay graduation but is taken
in addition to the student’s normal full-time course load, the IHS
Scholarship Program will pay tuition only for the non-repeated
courses. Payment of the stipend will not be affected in this case.

If a student has been granted a leave of absence from their
school, the maximum time granted for leave of absence from
the IHS Scholarship Program is a total of two consecutive
academic years. Need for further leave of absence will be
reviewed on a case-by-case basis.
THE IHS SCHOLARSHIP PROGRAM WILL SUSPEND THE
PAYMENT OF STIPENDS WHEN:
» A Recipient’s Initial Program Progress Report
(Form IHS-856-10) is not received within 30 days
of the beginning of the semester/quarter; or
» A student fails to submit official transcripts within
30 days for the fall and spring semester. Quarterly
transcripts should be sent within 30 days of the end
of the quarter.
The Scholarship Program will not reinstate suspended stipend
funds until the above-mentioned reports/transcripts have been
received. These payments will not be issued until the next
automated stipend cycle.

Section C: Continuation Support
Notice to all Continuation Students
The application deadline date for the IHS Scholarship Program
is March 28 of each year. If this date falls on a weekend or
holiday, the deadline will be the next business day.
If your application is incomplete as of the deadline date,
the IHS Scholarship Program will notify you one time
regarding your incomplete application and request the
appropriate documents.
If you do not complete the application within 90 days, you
will be automatically placed on leave of absence for a period
of one academic year beginning August 1 of the year in
which you applied.
You will be given an opportunity to file as a continuing
student in the next application cycle. A complete application
must be received by the deadline date of March 28. Your
name will be placed on the mailing list for an application for
the following year.
Please keep the IHS Scholarship Program Office informed
of any address change or other changes in your contact
information, so that an application can be sent to you in a
timely manner. Our address is:
IHS Scholarship Program
801 Thompson Ave., Suite 120
Rockville, MD 20852

Section C: Continuation Support
Health Professions Preparatory
Scholarship Program

Health Professions
Scholarship Program

Students must apply annually and meet the following criteria:

Students must apply annually and meet the following continued
eligibility criteria:

» Be in good academic standing in their program.
» Be enrolled for the next semester/quarter in at least 12
credit hours or the equivalent (full-time), or six to 11 credit
hours (part-time) in courses specific to a pre-professional
curriculum.
» Remain full-time or part-time during the current
academic year.

Health Professions Pre-Graduate
Scholarship Program

» Maintain an overall 2.0 grade point average in their
chosen health/allied health professions curriculum.
» Be enrolled for the next semester/quarter in at least 12
credit hours or the equivalent (full-time), or six to 11 credit
hours (part-time).
» Submit a letter from the program director verifying the fulltime or part-time status of that institution’s health or allied
health program.

To receive priority consideration for additional periods of
scholarship support, students must meet the continued
eligibility requirements and be recommended for continuation
by the appropriate discipline chief.
Students must apply annually and meet the following continued
eligibility criteria:
» Be in good academic standing in their pre-professional
program.
» Be enrolled for the next semester/quarter in at least
12 credit hours or the equivalent (full-time), or six to
11 credit hours (part-time) in courses specific to a preprofessional curriculum.
» Remain full-time or part-time during the current
academic year.

Section D: Payback/Service
Obligation for Health
Professions Scholarship
Program Recipient

Obligation for Health Professions
Section D: Payback/Service
Scholarship Program Recipient

Requirements of Health Professions
Scholarship Program Graduates
Health Professions Scholarship Program recipients incur a
service obligation of one year for each year of scholarship
support received (or the part-time equivalent) with a minimum
service period of two years. After graduation, your active duty
service obligation is fulfilled as designated by the Director of
IHS, in one of the following areas:

Application/Placement Process
Graduating students may apply for employment through the
federal Civil Service or the US Public Health Service Commissioned Corps.
Whether your application is submitted to the IHS Civil Service or
Commissioned Corps, be sure to indicate clearly that you are a
scholarship program graduate. This will assure that you receive
priority consideration for jobs for which you qualify.

» Indian Health Service (IHS).
» A program conducted under a contract or compact entered
into under the Indian Self-Determination Act (P.L. 93-638),
as amended.
» Urban Indian organization assisted under Title V of the Indian
Health Care Improvement Act (P.L. 94-437), as amended.
» Private practice in a designated health professional shortage
area addressing the health care needs of 51 percent of
Indians in that area.

Final transcripts must be sent to the IHS Scholarship
Program before your service payback can be counted.

Civil Service
If you opt for the Civil Service system within IHS, you must
submit the following forms and all other additional required
forms (e.g., transcripts) to the vacancy announcement’s IHS
Area Personnel Office by the deadline:
» Optional Application for Federal Employment (Optional
Form 612) or a resume

The scholarship recipient may elect to fulfill the service obligation in one of the above areas that is located on the reservation
of the Tribe or serves the Tribe in which the recipient is enrolled.

» Verification of Indian Preference for Employment
(BIA-4432)

Assignment opportunities are reviewed with students and
approved early in the final school year. The Director of IHS
reserves the right to make final decisions regarding assignment
of scholarship recipients to fulfill their service obligation.

All forms can be requested from any government office
except the Verification of Indian Preference for Employment
(BIA-4432), which must be obtained from the Bureau of Indian
Affairs. They can also be found online at www.opm.gov.

Although the ultimate responsibility for seeking a
position is the Health Professions Scholarship recipient’s,
the IHS Scholarship Program staff and IHS Discipline
Representatives are available to assist with and
facilitate placement. Please visit www.careers.ihs.gov
for more information.
According to the Indian Health Care Improvement Act and the
Public Health Service Act, the active duty service obligation
must be served in a full-time (40 hours per week) clinical
practice. You will have an opportunity to find placement to
serve your active duty service obligation, consistent with the
statutory mandates listed above. However, if there is a difficulty
in placement, you may be assigned to an IHS geographic area
where there is an existing need.

Commissioned Corps of the USPHS
You may wish to apply for service through the Commissioned
Corps if your health profession is any of the following:
medical, dental, nursing (BSN, MSN), pharmacy, engineering,
physical therapy, dietetics, sanitarian, or master’s-level
health professional training. To receive information and an
application, contact:
Office of Commissioned Corps Operations
Division of Commissioned Corps Assignments
1101 Wootton Parkway, Plaza Level, Suite 100
Rockville, MD 20852
Telephone: (240) 453-6125; 1(800) 279-1605
www.usphs.gov
Once the Division of Commissioned Corps Assignments verifies
your application is complete, you must submit required forms to
the IHS Area Personnel Office by the deadline date as indicated
in the vacancy announcement.

Obligation for Health Professions
Section D: Payback/Service
Scholarship Program Recipient

For information regarding benefits relating to salary, travel pay,
health benefits, housing, etc., you must contact the IHS Area
Personnel Office to which you are applying.

Monitoring the Placement Process
All graduating students must apply for current employment
vacancies. The IHS Discipline Representatives and Area Scholarship Coordinators will offer professional advice and assist you
with job vacancies in your field.
The monitoring of the graduating student’s progress towards
placement involves the following:
» At least one month before graduation, you must contact the
IHS Scholarship Program via a Notice of Impending Graduation (Form IHS-856-15).
» At least three months before you graduate, the IHS
Scholarship Program Headquarters reminds you of your
placement responsibilities and to send completed forms to
your Area Scholarship Coordinator with a copy to your Discipline Representative and IHS Scholarship Program. Forms
to be completed are: Optional Application for Federal
Employment (Optional Form 612); Health Profession
Scholarship Program Service Preferred Assignment
(Form IHS-856-19); and, if applicable, a Verification of
Indian Preference for Employment (BIA-4432) form.
Note: Priority will be given to IHS Scholarship Program
recipients. As such, please indicate on your documents that
you are to receive such priority.

» Once a position is secured, you must submit information
regarding verification of employment within 90 days of your
graduation date.
The Director of IHS reserves the right to make final decisions
regarding assignment of scholarship recipients to fulfill their
service obligation according to the needs and priorities of IHS
and Tribes.
Prioritization of sites will vary from year to year and among
the different health profession disciplines. An updated list can
be found at www.scholarship.ihs.gov. You may contact your
Discipline Chief for information regarding placement. Although
IHS will attempt to place you in the geographic location of your
choice, this may not be possible and you may be required to
take a position in another location.

Documentation Requirements
Before any scholarship recipient receives credit toward
their service obligation, the IHS Scholarship Branch
requires the following documentation:
A copy of your diploma and official final transcript stating degree
conferred, and any of the following items that are applicable in
your case:
» A copy of your license/certificate (for those disciplines that
need one to work).
» If federal employment,

» The graduating student should send a copy of all documents
to each Area Scholarship Coordinator in the Areas where they
are interested in working.

– a copy of your Civil Service Personnel Action Form
(SF-50) from your personnel office reflecting your
entrance on duty date and any copies of SF-50, if you
should transfer during your payback status, or

» Follow-up with each respective Area Scholarship Coordinator
and Discipline Representatives should be done each month
by the graduating student regarding vacancies available and
application status.

– a copy of your Commissioned Corps Personnel Orders
calling you to duty and copies of personnel order transfer
papers if you should transfer during your
payback status.

» A Placement Update (Form IHS-856-14) must be sent to
the IHS Scholarship Program within 60 days of graduation
and every 60 days thereafter. The graduate must attach
documentation regarding attempts at securing employment
(e.g., letter of application receipt, denial letters). This form
may also be used to express any type of dissatisfaction, or
problems encountered while seeking a position.

» If Tribal employment, a contract, work agreement or
letter from the Tribe indicating start date of employment.
» If a private practice option, a contract, work agreement or
letter from the facility indicating start date of employment.
Deadline: The appropriate documentation is required 90
days from the date of graduation.

If the IHS Scholarship Branch does not receive the information
required, we will assume that you did not graduate and are
not paying back your service obligation. Failure to submit the
information may result in the initiation of debt collection action.
Additionally, you must submit an Annual Status Report (Form
IHS-856-18). This is required to monitor your payback obligation activity, so that credit can be given to your obligation.

» To be eligible to serve with the IHS as a licensed social
worker, and before they can sit for licensure boards, graduates must complete two years of clinical experience under a
licensed practitioner. This requirement may vary based upon
geographic location.

If you have any questions regarding these directions, contact
the IHS Scholarship Program.

» To be eligible to serve with the IHS as a licensed clinical
psychologist, and before they can sit for licensure boards,
graduates must complete two years of clinical experience
under a licensed practitioner. This requirement may vary
based upon geographic location.

Deferments

» To serve with IHS as a registered pharmacist, graduates
may elect to complete one additional year of residency
in pharmacy.

Post-Graduate Training
Health Professions Scholarship recipients can defer their service
obligations for further training. Detailed information on this
procedure is given in the spring of your senior year and is
outlined below. As an IHS scholarship obligated graduate, it is
your responsibility to familiarize yourself and comply with the
information bulletin and instruction you will receive. Failure to
do so may result in non-approval of your deferment request.
Deferment of the service obligation is intended to permit
scholarship recipients to complete approved graduate clinical
training programs, i.e., those programs of graduate clinical
training which fulfill the requirements for board certification and
have been approved by the appropriate certifying boards, as
determined by the Secretary, Department of Health and Human
Services. Training which fulfills the requirements for board
certification is considered by the IHS Scholarship Branch to be
the graduate clinical training and years of practice required by
the appropriate American specialty board for the candidate to
be board certified.
To be eligible to serve with IHS as an allopathic or osteopathic
physician, graduates must complete at least one year in an
approved graduate clinical training program. Completion of
postgraduate training is a critical factor in identification of the
practice in which the scholarship obligation is to be fulfilled.
Scholarship recipients who elect to serve after only one year of
graduate clinical training will compete with board eligible practitioners for a limited number of vacancies and may experience
difficulty in identifying assignments in which to serve. Therefore,
in order to become fully qualified practitioners, graduates are
encouraged to complete training in an approved specialty.

Note: No period of internship, residency or other advanced
clinical training shall be counted as satisfying any period of
obligated service that is required under Section 104 (b)(3)(A)
of the IHCIA, P.L. 94-437, as amended.

Specialties and Approval
All medical school graduates will receive a letter from
the Chief of the Health Professions Support Branch indicating
which specialties you may enter for your post-graduate
training residency. The specialties are determined according
to IHS needs.
Specialties: The following is a list of specialties that are
currently in demand throughout IHS:
» Family Medicine
» Obstetrics and Gynecology
» Internal Medicine
» Pediatrics
» Emergency Medicine
» Psychiatry
Prior Approval: Initial approval of your post-graduate training
plan is contingent upon full compliance with all policies and
procedures applicable to the deferment of all graduates, and
upon you request to enter a specialty needed by IHS. The IHS
Scholarship Branch requires that you submit a request for
residency training before beginning a residency by submitting a
Request for Prior Approval or Deferment (Form IHS-856-20).

Obligation for Health Professions
Section D: Payback/Service
Scholarship Program Recipient

If you do not submit this request, your residency or clinical
training will not be approved and you may be placed in default.

After Deferment Approval: Your deferment will continue if you
comply with these conditions:

You cannot transfer to another residency without prior approval
from IHS Scholarship Branch.

» Pursue only the training as described, in an accredited
program approved by the IHS Scholarship Program,
and for a deferment that does not incur a conflicting
service obligation.

Those who are unsuccessful in obtaining an internship or
residency must notify IHS immediately and will be expected to
begin obligated service upon completion of their first year of
training. They will be assigned according to the needs of IHS if
notification is received after September 1.
IHS physicians have found that they are significantly less
competitive in locating sites in target IHS Areas if they are not
board eligible/certified.
IHS Areas are preferentially seeking fully trained and qualified
individuals who have a higher probability of remaining after
completion of their service obligation, rather than leaving to
pursue further graduate training.
Approved Deferments: Approval of deferment of the service
obligation for all graduates will be based on the return of the
Request for Prior Approval or Deferment (Form IHS-856-20).
New graduates, as well as those granted deferment who intend
to continue in deferment status during the cycle, must submit
these forms.
The Request for Prior Approval or Deferment (Form
IHS-856-20) must be submitted annually until you
have completed your residency. If you fail to return
the form, you will be placed in default.
All IHS Scholarship Recipients who wish to defer their service
obligation for the period from July 1 through June 30 must
complete, sign, and return the Request for Prior Approval
of Deferment (Form IHS-856-20) by May 31. The deferment
request packet will be mailed to you during the third year of
your health profession program.

» Submit documentation of your training status in an approved
program each year of deferment.
» Make no changes in the period, place of training or type of
training without prior approval from the IHS Service Branch.
» Notify the IHS Scholarship Branch in writing within 30 days
of any change of address, intent to terminate training, intent
to take a break in training, or similar change.
» Notify the IHS Scholarship Branch in writing if you did not
pass PGY I level of training and did not go in the PGY II level.
Your program director should also send a letter to the IHS
Scholarship Branch.
» Return the deferment request by the deadline date of
May 31.
» Physicians who elect to begin their obligated service before
completing their second, third or fourth year of training in an
approved specialty must notify the IHS Scholarship Branch
upon making the decision.
If you do not comply with all the above, you will be in
default of your scholarship contract. The IHS Service Branch
has adopted the above procedures because of problems
with deferments during the previous years.
Please Note: All deferment deadline dates and policies will be
strictly enforced.
If you need additional information regarding deferment of your
service obligation or if you need assistance with your training
plans as they relate to your scholarship, please write to the IHS
Scholarship Program.

Section E:

Breach and Default
of Contract

SECTION E: Breach and Default of Contract
Failure to Complete
Academic Training
Health Professions Scholarship participants who are dismissed
from school for academic or disciplinary reasons, or who
voluntarily terminate academic training before graduation
from the educational program for which the scholarship was
awarded, will be liable to the United States for repayment of
all Scholarship Program funds paid to them and to the school
on their behalf. Payment must be made within three years
from the date of breach or such longer period as specified by
the Secretary. No interest will be charged on any part of this
indebtedness to the United States within the three-year period.

scholarship funds paid to them and to the school on their behalf,
plus interest, as determined by the formula: A=3(z)[(t-s)/t], in
which:
» ‘A’ is the amount the United States is entitled to recover
» ‘z’ is the sum of the amounts paid to or on behalf of the
applicant and the interest on such amounts that would be
payable, if, at the time the amounts were paid, they were
loans bearing interest at the maximum legal prevailing rate,
as determined by the Treasurer of the United States
» ‘t’ is the total number of months in the applicant’s period of
obligated service

Failure to Begin or Complete
the Service Obligation or
Meet the Terms and Conditions
of Deferment
Participants breach their scholarship contracts by failing to begin
or complete their service obligation for any reason other than
failure to complete academic training, or by failing to comply
with the terms and conditions of deferment. In these cases,
participants are liable to repay three times the amount of all

» ‘s’ is the number of months of the period of obligated
service served by the participant
The amount which the United States is entitled to recover shall
be paid within 1 year of the date on which the applicant failed
to begin or complete the period of obligated service, or failed to
meet the terms and conditions of deferment, or a longer period
beginning on a date specified by the Secretary of Health and
Human Services (HHS).

SECTION F: Extern Program
Overview
The recruitment and placement process of the Indian
Health Service Scholarship Extern Program is a major
annual activity of the IHS Scholarship Program.
Individuals receiving an IHS scholarship award and other
health professionals may be employed as an IHS extern for
up to 120 workdays per calendar year. Health Professions
Scholarship recipients are entitled to an externship. Extern
assignments are available during non-academic periods.
Students are assigned to an IHS health care facility where
they will accumulate valuable clinical hours in their chosen
health disciplines. This opportunity to apply the knowledge
and skills developed in school provides practical hands-on
experience that will be useful once they graduate.

SECTION F: Extern Program
Eligibility
Individuals receiving a Health Professions Scholarship are
entitled to employment by IHS during any non-academic
period in accordance with the provisions of Section 105 of
the Indian Health Care Improvement Act. (Note: This does
not prohibit scholarship recipients or any other qualifying
student from doing an externship and going to school as
long as IHS is not paying tuition/fees during that time
frame.) Students who are completing a rotation, whether
clinical or on-the -job experience, that is part of a course
requirement are not eligible.

Civil Service
Students who apply for a Civil Service externship must meet the
following requirements:
» Undergraduate students must have at least a 2.0 grade point
average; graduate students must have at least a 3.0 grade
point average.
» Students must not be on probation or discontinued from the
IHS Scholarship Program for any reason.

Commissioned Corps
Students may also apply to the Commissioned Officer Student
Training and Extern Program (COSTEP), by contacting:
Junior COSTEP
Recruitment/DCCTCP
Tower Building, Plaza Level, Suite 100
1101 Wootton Parkway
Rockville, MD 20852
Phone: (240) 453-6072
www.usphs.gov
In addition to the COSTEP application, students must submit all
application materials listed below.

Application
Students seeking an externship either through Civil Service or
COSTEP, must submit the following documents to the IHS Area
Coordinator in the IHS Area Office in which they are seeking
placement:
» Resume or Application for Federal Employment
(Form OF-612) that can be downloaded at www.opm.gov
» Extern Site Preference Request (Form IHS-856-16)

Deadlines for COSTEP applications are:
» Official transcripts
» December 31 for positions May 1 through August 31.
» May 1 for positions during September 1 through
December 31.
» October 1 for positions during January 1 through April 30.

» Request for Extern Travel Reimbursement
(Form IHS-856-17)
» Proof of immunity to measles and rubella. All applicants to
positions located at an IHS facility shall provide documentation of immunity to measles and rubella prior to or at the
time of their entrance on duty. Employees subject to this

SECTION F: Extern Program
policy who are not immune to measles or rubella and refuse
the recommended vaccine(s) are subject to be reassigned or
removed from the service.
» Proof of possession of the following: Social Security card
(number), driver’s license, and Employment Eligibility
Verification (BIA Form 4432).

» GS-9: master’s degree or equivalent graduate degree or
two full years of progressively higher graduate education
leading to a degree such as Bachelor of Laws (LLB) or JD
(Juris Doctor), if related.
» GS-11” PhD or equivalent doctoral degree or three full years
of progressively higher level graduate education leading to a
degree such as Master of Laws (LLM), if related.

» Documentation of enrollment in the fall term.

Travel
Application Due Date
Completed, signed and dated applications must be received
by the Area Coordinator before close of business on the first
Friday on the month of February. COSTEP applications are due
as outlined above.

Benefits
Salary
Externs may receive a salary based on experience and years
of academic training that is comparable to industry standard.
Salary is waived if the externship fulfills a required field
placement or an internship required under a health profession
education program, in which case IHS will pay school tuition
and fees.
Note: The salary is based on the student’s experience and
the number of completed semester hours in their academic
program according to Personnel Standards, rules and regulations. The ratings listed below are proposed grade levels based
on the number of credit hours completed. The personnel office
responsible for the extern position will determine your grade
level.
» GS-3: 30 semester hours/45 quarter hours
» GS-4: 60 semester hours/90 quarter hours
» GS-5: bachelor’s degree (120 semester hours/180
quarter hours)
» GS-7: First year of graduate school (18 semester hours of
graduate education, 27 quarter hours of graduate selection)

Extern may request travel reimbursement for one round trip to
the extern site. The request for Extern Travel Reimbursement
(Form IHS-856-17) must be completed and submitted prior
to travel.
Travel reimbursements are authorized based on the travel and
transportation allowance under federal regulations.
If an advance for travel is required, you may work directly
through your coordinator and the Area Office, Service Unit or
health clinic where you are assigned.
Do not, under any circumstances, travel without
authorized travel orders.

Housing
Students are responsible for finding their own housing. Information on housing may be available from the Area Coordinator,
Discipline Representative and/or Extern Preceptor. A minimal
allowance can be made for transportation of goods, but requires
authorization on your travel orders.
Please stay in touch with your area scholarship coordinator and extern preceptor to verify all your arrangements before traveling to the extern site.

SECTION G: Contact Information
Overview
This section describes key personnel involved with your
scholarship award and includes their location and contact
information. Submit your required reports and forms to
the appropriate person and feel free to contact that person
with any questions you might have. The IHS Scholarship
Program staff is ready to help you and has an interest in
your success.
You can also access information about specific personnel at
www.scholarship.ihs.gov.

SECTION G: Contact Information
Area Office Scholarship
Coordinators, Indian Health
Service Area Offices and
Special Scholarship Offices
A complete listing of the Indian Health Services Area Offices,
Scholarship Coordinators and Special Scholarship Offices is in
this section. The role of the Area Scholarship Coordinator is
to serve as your primary contact within IHS for technical and
programmatic questions, to monitor your academic performance and to assist you with the placement process. This is
the first person you should contact with questions concerning
your scholarship.
Aberdeen Area IHS (Iowa, Nebraska, North Dakota,
South Dakota)
Federal Building, Room 309
115 4th Ave. SE
Aberdeen, SD 57401
Phone: (605) 226-7532
Fax: (605) 226-7321

Billings Area IHS (Montana, Wyoming)
2900 4th Ave. North, Suite 400
Billings, MT 59101
Phone: (406) 247-7100
Fax: 406-247-7245 or 406-247-7230
California Area IHS (California, Hawaii)
650 Capitol Mall, 6th Floor
Sacramento, CA 95814
Phone: (916) 930-3981 Ext. 724
Fax: 916-930-3952
Eastern United States IHS (Alabama, Arkansas, Connecticut,
Delaware, Florida, Georgia, Kentucky, Louisiana, Maine,
Maryland, Massachusetts, Mississippi, New Hampshire, New
Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode
Island, South Carolina, Tennessee, Texas, Vermont, Virginia,
West Virginia and District of Columbia)
711 Stewarts Ferry Pike
Nashville, TN 37214
Phone: (615) 467-1500
Fax: 615-467-1501

Alaska Area Native Health Services (Alaska)
4000 Ambassador Drive
Anchorage, AK 99508
Phone: (907) 729-1337, (907) 729-1332 or (800) 684-8361
Fax: 907-729-1335

Navajo Area IHS (Arizona, New Mexico, Utah)
PO Box 9020
Window Rock, AZ 86515
Phone: (928) 871-1358 or (928) 871-1422
Fax: 928-871-1383

Albuquerque Area IHS (Colorado, New Mexico)
5300 Homestead Road NE
Albuquerque, NM 87110
Phone: (505) 248-4948
Fax: 505-248-4938
Bemidji Area IHS (Illinois, Indiana, Michigan,
Minnesota, Wisconsin)
Federal Building, Room 209
522 Minnesota Ave. NW
Bemidji, MN 56601
Phone: (218) 444-0486
Fax: 218-444-0498

Oklahoma City Area IHS (Kansas, Missouri, Oklahoma)
5 Corporate Plaza
3625 NW 56th St.
Oklahoma City, OK 73112
Phone: (405) 951-6040 or (800) 722-3357
Fax: 405-951-3953
Phoenix Area IHS (Arizona, Nevada, Utah)
2 Renaissance Square
40 N. Central Ave., #510
Phoenix, AZ 85004
Phone: (602) 364-5253
Fax: 602-364-5358

SECTION G: Contact Information
Portland Area IHS (Idaho, Oregon, Washington)

Injury Prevention

Federal Building, Room 440
1220 SW 3rd Ave.
Portland, OR 97204
Phone: (503) 326-6983
Fax: 503-326-2702

Indian Health Service, HQE
12300 Twinbrook Parkway, Suite 610
Rockville, MD 20852
Phone: (301) 443-0105
Master of Public Health: Epidemiology

Tucson Area IHS (Southern Arizona)
7900 South Stock Road
Tucson, AZ 85746
Phone: (520) 295-2440
Fax: 520-295-2438

Division of Epidemiology
5300 Homestead Road NE, Room 3028
Albuquerque, NM 87110
Phone: (505) 248-4226
Master of Public Health: Health Care Administration

IHS Discipline Representative
The role of the IHS Discipline Representative of your particular
health discipline is to monitor your academic performance in
order to assure your success in your health education. The Discipline Representative also assists Health Professions Scholarship
recipients with extern and service obligation placements and
with placement to complete their service obligation. Please
refer to the following listing of Discipline Representatives.
You can also access information about specific personnel at
www.careers.ihs.gov.
Accounting
Indian Health Service, HQE
12300 Twinbrook Parkway, Suite 360
Rockville, MD 20852
Phone: (301) 443-1270
Coding Specialist
Indian Health Service, PHX
2 Renaissance Square
40 N. Central Ave., Suite 606
Phoenix, AZ 85004
Phone: (602) 364-5162
Computer Science
Indian Health Service
12300 Twinbrook Parkway, Suite 300
Rockville, MD 20852
Phone: (301) 443-3369

Indian Health Service, HQE
Office of Management Support
12300 Twinbrook Parkway, Suite 625
Rockville, MD 20852
Phone: (301) 443-2650
Master of Public Health: Health Education
IHS Health Education Program
PO Box 752
984 Acquoni Road
Cherokee, NC 28719
Phone: (828) 292-1175
Medical Records
Indian Health Service
PHX 2 Renaissance Square
40 N. Central Ave., Suite 606
Phoenix, AZ 85004
Phone: (602) 364-5162
Optometry/Optician
Chief of Optometry
Quentin N. Burdick Memorial Health Care Facility
1 Hospital Way
Belcourt, ND 58316
Phone: (701) 477-8413

Physician Assistant/Pre-Medical Physician/
Osteopathy Physician/Allopathy
Director
Division of Planning, Evaluation, and Research
Office of Public Health Support
12300 Twinbrook Parkway, Suite 450
Rockville, MD 20852
Phone: (301) 443-4700
Pre-Clinical Psychology/Clinical Psychology/
Chemical Dependency Counseling/Counseling Psychology
Indian Health Service, HQE
801 Thompson Ave., Suite 300
Rockville, MD 20852
Phone: (301) 443-2038

Pre-Dentistry/Dentistry/Dental Hygiene
Chief, Dental Program
801 Thompson Ave., Suite 300
Rockville, MD 20852
Phone: (301) 443-1106
Pre-Dietetics/Dietetics/ Public Health Nutrition
Indian Health Service, HQE
801 Thompson Ave., Suite 300
Rockville, MD 20852
Phone: (301) 443-0576
Pre-Engineering/Engineering
Indian Health Service, HQE
Environmental Health and Engineering
12300 Twinbrook Parkway, Suite 610
Rockville, MD 20852
Phone: (301) 443-1046
Pre-Medical Technology/Medical Technology
Phoenix Indian Medical Health Center
2 Renaissance Square
40 N. Central Ave., Suite 606
Phoenix, AZ 85004
Phone: (602) 364-5186
Pre-Nursing/Associate Degree Nurse/Geriatric Nursing/
Registered Nurse Anesthetist/Nurse with minimum of a
Baccalaureate Degree in Nursing/Pediatric Nursing/
Psychiatry Nursing/Women’s Health Nursing
Director, DNS
801 Thompson Ave., Suite 324
Rockville, MD 20852
Phone: (301) 443-1026
Pre-Pharmacy/Pharmacy
Director, Pharmacy Program
801 Thompson Ave., Suite 311
Rockville, MD 20852
Phone: (301) 443-1190

SECTION G: Contact Information
Pre-Physical Therapy/Physical Therapy/Physical Therapist
Assistant/Pre-Occupational Therapy/
Occupational Therapy
Indian Hospital
In-Patient Physical Therapy
1001 N. Country Club Drive
Ada, OK 74820
Phone:(580) 436-3980
Pre-Podiatry/Podiatry
Phoenix Indian Medical Center
4242 N. 16th St.
Phoenix, AZ 85016
Phone: (602) 263-1673
Pre-Sanitation/Environmental Health: Sanitation
Indian Health Service, HQE
Environmental Health and Engineering
12300 Twinbrook Parkway, Suite 610
Rockville, MD 20852
Phone: (301) 443-1054
Pre-Social Work/Social Work
Indian Health Service, HQE
Behavioral Health
801 Thompson Ave., Suite 300
Rockville, MD 20852
Phone: (301) 443-2038
Radiologic Technology/Ultrasonography
Deputy Director, Medical Imaging Program
2 Renaissance Square
40 N. Central Ave., Suite 600
Phoenix, AZ 85004-4424
Phone: (602) 364-5166

IHS Scholarship Branch Chief
The IHS Headquarters Scholarship Branch Chief is responsible
for the coordination of the programmatic aspects for the five
sections of P.L. 94-437, Title I, and for the activities of the Area
Scholarship Coordinators. Additionally, the IHS Headquarters
Scholarship Branch Chief serves as the authority on programmatic issues and decisions. The mailing address is:
IHS Scholarship Branch Chief
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-6197
Fax: 301-443-6048

IHS Scholarship Award Program
Compliance Analyst
The IHS Scholarship Award Program Compliance Analysts are
responsible for the coordination of the various scholarship
program functions and processes and, as part of this responsibility, work with scholarship recipients so that the recipients
comply with their obligations and/or liabilities. The analysts
monitor the deferment and completion of the recipients’
service obligation. In addition to these duties, analysts work
with the Division of Grants Operations on matters dealing with
payments, applications/awards, and related processing. The
analysts track and record data pertaining to the recipients and
monitor their academic progress to ensure compliance while
the students are in school. Analysts maintain ongoing communications with the Area Scholarship Coordinators, as well as
with other IHS components, governmental agencies and Tribal
organizations. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-6197
Fax: 301-443-6048

Respiratory Therapy
Indian Hospital
In-Patient Physical Therapy
1001 N. Country Club Drive
Ada, OK 74820
Phone: (580) 436-3980

Default Waiver Coordinators
The Default Waiver Coordinators monitor the default/waiver
functions of the IHS Scholarship Award Program. The mailing
address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-6197
Fax: 301-443-6048

Scholarship Applications/
Award Analyst
The Scholarship Application/Awards Analyst monitors scholarship recipients, determines compliance with prescribed
guidelines and makes recommendations if recipients are in
noncompliance. The analyst also prepares and distributes
materials to applicants, recipients and schools regarding the
Scholarship Program. The analyst is also responsible for the
following: transfer of schools, leave of absence, change in
graduation date, reporting requirements relating to progress
reports/ transcripts, academic problems, and requests for
tutorial services and summer school. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-6197
Fax: 301-443-6048

Scholarship Program
Extern Coordinator
The IHS Scholarship Extern Coordinator is responsible for the
funding of the IHS Scholarship Extern Program. The coordinator
verifies and reconciles data on all externs by Area Office. The
coordinator also establishes and maintains cooperative and
ongoing communications with Area Scholarship Coordinators as
well as other IHS components, government agencies and Tribal
organizations to ensure that externs are in compliance with
Scholarship Program requirements. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-6197
Fax: 301-443-6048

IHS Division of Grants
Operations Officer

IHS Grants Scholarship Coordinator
The IHS Grants Scholarship Coordinator is responsible for
the coordination of all business functions of the scholarship
program. These include application distribution, obligation
of funds, award notifications, and payment of invoices and
monthly stipends. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-5204
Fax: 301-480-1091

IHS Scholarship Grants
Management Specialist
The IHS Scholarship Grants Management Specialist is responsible for the issuance of stipends (monthly) and other reasonable costs (yearly), and for the authorization of tuition and
mandatory fees. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-5204
Fax: 301-480-1091

Health Professions Support
Branch Chief
The Health Professions Support Branch Chief is responsible for
coordinating the identification and approval of specialties for
post-graduate residency training programs for physicians. The
mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-4242
Fax: 301-443-1071

The IHS Division of Grants Operations is responsible for the
administration of the scholarship program in accordance with
grant policies and procedures. In addition, all management of
appropriate business functions of the scholarship program is the
Officer’s responsibility. The mailing address is:
801 Thompson Ave., Suite 120
Rockville, MD 20852
Phone: (301) 443-5204
Fax: 301-443-9602

SECTION H: Sample Contracts
Overview
This section describes key personnel involved with your
scholarship award and includes their location and contact
information. Submit your required reports and forms
to the appropriate person and feel free to contact that
person with any questions you might have. IHS Scholarship
Program staff is ready to help you and has an interest in
your success.
You can also access information about specific personnel at
www.scholarship.ihs.gov.

SECTION H: Sample Contracts

HEALTH PROFESSIONS PREPARATORY AND PREGRADUATE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE

EDUCATION SCHOLARSHIP PROGRAM AGREEMENT

INDIAN HEALTH SERVICE

SCHOOL YEAR 2007 - 2008

Section 103 of the Indian Health Care Amendments of 1988 authorizes the Secretary of Health and Human Services
("Secretary"), acting through the Indian Health Service, to provide applicants selected to be participants in the Health
Professions Preparatory and Pregraduate Education Scholarship Program for Indians ("Scholarship Program") with scholarship
awards. The statute is codified at 25 U.S.C. 1613 and the implementing regulations are codified at 42 CFR, Part 36, Subpart J,
Subdivision J-3. In return for awards, applicants must indicate an intent to serve Indians as health care professionals in the
discipline or specialty for which the award is given upon completion of their health care professional education.
Program policy requires applicants to submit with their applications a signed Agreement which states the terms and
conditions of participation in the Scholarship Program. The Secretary shall sign only those Agreements submitted by applicants
who are selected for participation.
The terms and conditions of participating in the Scholarship Program for the 2007-2008 school year are set forth below.
Section A -- Obligations of the Secretary
Subject to the availability of funds appropriated by the Congress of the
United States for the Scholarship Program of the Indian Health Service
("IHS"), the Secretary agrees to provide the undersigned applicant
("applicant") with a scholarship award for the school year 2007-2008
during which the applicant must be:
1. enrolled, or is accepted for enrollment, as a full-time or part-time
student in an accredited (as determined by the Secretary) educational institution in on of the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of the
Northern Mariana Islands, the Virgin Islands, Guam, or American
Samoa, and
2. pursuing a preparatory education course or curriculum necessary
for enrollment or reenrollment in a health professions school, or
3. pursuing pregraduate education leading to a baccalaureate degree in
premedicine, prenursing, predentistry, prepharmacy, prephysical
therapy, or other health profession which has been determined to be
needed by the Indian Health Service for participation in the
Scholarship Program.
The Scholarship award may consist of payments, in whole or in part, for
tuition, an amount of all other reasonable educational expenses incurred by
the student, and a monthly stipend for the academic period covered by the
award beginning with the first month of each school year in which the
applicant is a participant in the Scholarship Program.

Section B -- Obligations of the Applicant
The applicant agrees:
1. to accept the scholarship award provided to the Secretary under
Section(A) of this Agreement for the school year 2007-2008;
2. to maintain full-time or part-time enrollment until completion of the
course of study for which the scholarship award is provided;
3. to maintain an acceptable level of academic standing while enrolled in the course of study for which the scholarship award is
provided; and

4. that it is his/her intent to provide services to Indians, as a full-time
practitioner of the profession for which the education scholarship is
awarded, upon completion of the necessary education and training,
and that it is his/her intent that these services will be provided in the
Indian Health Service, an urban Indian organization assisted under
42 CFR, Part 36, Subdivision J-6 or in a health professional
shortage area designated under Section 332 of the Public Health
Service Act which address the health care needs of a substantial
number of Indians as determined by the Secretary in accordance
with guidelines of the Indian Health Service
Section C -- Breach of Agreement
If the applicant:
Withdraws from the educational program for any reason, or fails to
maintain an acceptable level of academic standing in the education
program for which the scholarship award is provided, the scholarship
award will be terminated and to be reinstated, the applicant will have to
apply and compete as a new applicant during the regular application
cycle.
Section D -- Extension of Scholarship Award
1. The applicant may annually request extension of this scholarship
award, for a period not to exceed 12 months, if the request is submitted in accordance with procedure established by the Secretary.
2. Subject to the availability of funds appropriated by the Congress of
the United States for the Indian Health Service Scholarship Program, the Secretary shall approve the request for an extension if:
a. The request does not extend the total period of scholarship
award beyond two (2) years for a preparatory education award
or beyond four (4) years for a pregraduate baccalaureate degree
award, and
b. The applicant is otherwise eligible for continued participation in
the Health Professions Preparatory and Pregraduate Education
Scholarship Program.

The Secretary or his/her authorized representative must sign this contract before it becomes effective.
Applicant Name (Please Print)

Secretary of Health and Human Services

IHS-817 (8/06)

Applicant's Signature

Date

PSC Graphics (301) 443-1090 EF

SECTION H: Sample Contracts

INDIAN HEALTH SCHOLARSHIP PROGRAM CONTRACT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE

SCHOOL YEAR 2007-2008

INDIAN HEALTH SERVICE

HEALTH PROFESSIONS

Section 104 of the Indian Health Care Amendments of 1988 authorizes the Secretary of Health and Human Services
("Secretary"), acting through the Indian Health Service, to provide applicants selected to be participants in the Indian Health
Service Scholarship Program ("Scholarship Program") with scholarship awards as established under Section 338A. In return
for awards, applicants must agree to provide health services in a manner determined by the Secretary for a period of obligated
service equal to one year for each year of scholarship award received, or two years, whichever is greater, Section 338A requires
applicants to submit with their applications a signed contract stating the terms and conditions of participation in the Scholarship
Program. The Secretary shall sign only those contracts submitted by applicants who are selected for participation.
The terms and conditions of participating in the Scholarship Program for the 2007-2008 school year are set forth below.

Section A -- Obligations of the Secretary

Subject to the availability of funds appropriated by the Congress of the United States for the
Scholarship Program and the Indian Health Service ("IHS"), the Secretary agrees to:
1. Provide the undersigned applicant ("applicant") with a scholarship award for the
school year 2007-2008 during which the applicant:
a. is enrolled, or is accepted for enrollment in an accredited (as determined by the
Secretary) educational institution in one of the several States, the District of Columbia,
the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana
Islands, the Virgin Islands, Guam, or American Samoa, and
b. is pursuing a course of study leading to a degree in medicine, osteopathy, dentistry,
or other health profession which has been approved by the Secretary for participation in the Scholarship Program.
The scholarship award may consist of payments, in whole or in part, for tuition, an
amount of all other reasonable educational expenses incurred by the student, and a
monthly stipend for the 12-month period beginning with the first month of each school
year in which the applicant is a participant in the Scholarship Program.
2. Utilize the applicant to provide health services in accordance with Section B(4) of this
contract.
3. Defer performance of an applicant's period of obligated service if the applicant: (1)
receives a degree from a school of medicine, osteopathy, dentistry, veterinary
medicine, optometry, podiatry or pharmacy, and (2) requests a deferment of this period
to complete internship, residency or other advanced clinical training. The period of
deferment may not exceed: (1) three years for applicants receiving a degree from schools
of medicine, osteopathy or dentistry, or (2) one year for applicants receiving a degree
from schools of veterinary medicine, optometry, podiatry or pharmacy. The Secretary
may, however, extend this period of deferment if the Secretary determines that the
extension is consistent with the needs of the IHS.
4. Release the Applicant from all or part of his or her service obligation to enter into the
full-time private practice of the applicant's health profession where the provisions of
Section 338C of the Public Health Service Act, 42 U.S.C. 254n and applicable IHS
policies are met. The release is applicable to service obligations incurred under either or
both the: (1) Public Health and Indian Health Scholarship Training Program (Section
225 of the Public Health Service Act as in effect on September 30, 1977), and (2) the
Indian Health Scholarship Program (Section 751 of the Public Health Service Act as in
effect on August 12, 1981, prior to its amendment and redesignation as Section 338A
of the Public Health Service Act.).
Section B -- Obligations of the Applicant
The applicant agrees to:
1. Accept the scholarship award provided by the Secretary under Section A(1) of this
contract for the school year 2007-2008.
2. Maintain full-time or part-time enrollment as determined by the Secretary until
completion of the course of study for which the scholarship award is provided.
3. Maintain an acceptable level of academic standing while enrolled in the course of
study for which the scholarship award is provided.
4. Serve his or her period of obligated service by providing health services, as determined
by the Secretary, in the Indian Health Service:
a. In the full-time practice of his or her health profession as a commissioned officer in
the Regular or Reserve Corps of the Public Health Service, a civilian employee of
the United States, or an individual who is not an employee of the United States,
providing service in the Indian Health Service, in a program conducted under a
contract entered under the Indian Self Determination Act, in a program assisted
under Title V of the Indian Health Care Improvement Act, such practice is situated
in a physician or other health professional shortage area, designated under Section
332, and addresses the health care needs of a substantial number of Indians; except
that scholarship recipients may at their election serve in one of the above programs
that is located on the reservation of the tribe in which the recipient is enrolled; or
serves the tribe in which the recipient is enrolled; or
b. In the full-time private clinical practice of his or her health profession under a
Private Practice option agreement (Section 338C of the Act) in a Health Manpower
Shortage Area for which designation under Section 332 of the Act has been
validated by the Secretary with the applicant's understanding that the full-time
private clinical practice option is subject to IHS primary responsibility to fill
vacancies within IHS and, in particular, IHS priority sites. Only after IHS vacancies
are filled will the applicant receive consideration for the other placement options.
5. Serve one year of obligated service for each year the scholarship award is provided, or
two years, whichever is greater.
6. Apply for and undertake placement in accord with established placement policies and
procedures.
7. Comply with provisions of Title 42, Code of Federal Regulations.

8. The applicant accepts the right of the Director, IHS to make final decisions regarding
assignment of scholarship recipients to fulfill their payback obligation.
Section C -- Breach of Scholarship Contract
If the applicant:
1. Fails to maintain an acceptable level of academic standing in the course of study for
which the scholarship award is provided, or voluntarily terminates academic training, or
is dismissed from the educational institution for disciplinary reasons, the applicant shall,
instead of performing the service obligation incurred under this contract, repay to the
United States all funds paid to the applicant and to the educational institution under this
contract. Payment of this amount must be made within 3 years of the date the
participant becomes liable to make payment under this paragraph. Obligors who fail to
complete their academic training or course of study for which the scholarship is
provided, for the reasons described herein, may not substitute another academic training
or course of study in order to fulfill any obligation incurred under this agreement.
However, obligors who obtain approval from the Director prior to breach of their
scholarship contract, may change their academic training or course of study for which
the scholarship is provided. The obligors newly approved training or course of study
will substitute as the professional discipline in which the obligor serves his or her
service obligation.
2. Fails to begin or complete the period of obligated service incurred under this contract for
any reason other than those in paragraph 1 of this section, the United States shall be
entitled to recover an amount equal to three times the scholarship funds awarded, plus
interest, as determined by the formula
(t-s)
A=3Ø
t
In which:
'A' is the amount the United States is entitled to recover,
is
the
sum
of
amounts
paid
to
or
on
behalf
of the applicant and the interest on
'Ø'
such amounts which would be payable if at the time the amounts were paid they
were loans bearing interest at the maximum legal prevailing rate, as determined
by the Treasurer of the United States,
is the total number of months in the applicant's period of obligated service, and
't'
is the number of months of such period served by the applicant in accordance
's'
with Section 338B of the Act or with a written agreement under Section 338C of
the Act.

The amount the United States is entitled to recover shall be paid within one year of the
date the Secretary determines that the applicant has failed to begin or complete the
period of obligated service and may include all collection costs including any litigation
costs.
Section D -- Creditability of Graduate Training Toward the Period of Obligated Service
1. No credit of time for internship, residency, or other advanced clinical training will be
counted toward satisfying the period of obligated service incurred under this contract.

Section E -- Cancellation, Suspension, and Waiver of Obligation
1. Any service or payment obligation incurred by the applicant under this contract will be
canceled upon the applicant's death.
2. The Secretary may waive or suspend the applicant's service or payment obligation
incurred under this contract if:
a. compliance by the applicant with the terms and conditions of this contract is
impossible or would involve extreme hardship, and
b. enforcement of such obligation would be unconscionable.
Section F -- Contract Extension
1. The applicant may annually request extension of this contract, for a period not to
exceed 12 months, if the request is submitted in accordance with procedure established
by the Secretary.
2. Subject to the availability of funds appropriated by the Congress of the United States
for the Scholarship Program and the IHS, the Secretary shall approve request for
contract extension if:
a. the request does not extend the total period of scholarship award beyond four
years, and
b. the applicant is otherwise eligible for continued participation in the Scholarship
Program
Section G -- Documents Incorporated by Reference

The Indian Health Service Scholarship Program (IHSSP) Student Handbook and the
IHSSP Applicant Information-Instruction Booklet are incorporated by reference into this
agreement.

The Secretary or his/her authorized representative must sign this contract before it becomes effective.
Applicant Name (Please Print)

Secretary of Health and Human Services

IHS-818 (8/06)

Applicant's Signature

Date

PSC Graphics (301) 443-1090 EF

SECTION I: Checklist

SECTION I: Checklist
Reporting

Continuation

The following is a checklist of all reporting requirements and
due dates. Please use this list to make sure that you meet all
deadlines and requirements. For more detailed information,
please see the Requirements section of this handbook.

The following is a checklist of all continuation activities and
due dates. Please use this list to make sure that you meet all
deadlines and requirements. For more detailed information,
please see the continuation section of this handbook.

ALL of the following reports and documents must be sent to:

All of the following forms are due February 28 of each
year to the IHS Division of Grants Operations.

IHS Scholarship Program
801 Thompson Ave., Suite 120
Rockville, MD 20852
q Initial Program Progress Report (Form IHS-856-10)
Due: Within 30 days from the beginning of each semester
or quarter.
q Official Transcript
Due: Within 30 days from the end of each academic period.
q Notification of Academic Problem or Change
(Form IHS-856-11)
Due: Immediately.

q Application: Continuation Students – Data Sheet (which you
will receive in the mail)
q Letter of Acceptance from College/Proof of Application to
Health Professions Program (Applicable to continuation
students who are transferring schools, changing from
103/103P to 104, or changing disciplines).
q Official Transcripts: Applicants Cumulative GPA
Calculations
q Delinquent Debt Form
q W-4 Form with original signature.

q Change of Academic Status (includes academic probation,
withdrawal from school and dismissal from school)
Due: Immediately.
q School Transfer Request
Due: At least 30 days prior to the time of transfer.

q Course Curriculum Verification with original signature
(If part-time, minimum of six credit hours).
q Acknowledgement Card
q Curriculum for Major

q Change of Health Discipline
Due: Prior to changing health discipline.

Health Professions Scholarship Program Only:
q Health Related Experience (MPH Only) – Optional Form

q Change in Graduation Date
Due: Immediately.
q Program Change
Due: At the end of the academic
funding year.
q Leave of Absence Request
Due: Immediately.
q Name Change
Due: Immediately.
q Change of Address
Due: Immediately.

SECTION I: Checklist
Additional Forms
The following is a checklist of all additional forms in the Forms
section and due dates. Please use this list to make sure that you
meet all deadlines and requirements.
q Lost Stipend Checks/Direct Deposit (Form IHS-856-9). Due:
Notify the Grants Scholarship Coordinator, Division of Grants
after the seventh day of the subsequent month from the
month missed.
q Request for Tutorial Assistance (Form IHS-856-12). Due: To
the IHS Scholarship Program, Scholarship Application/Award
Analyst and awarded permission prior to tutorial assistance.
q Summer School Request (Form IHS-856-14). Due: April 22 of
the academic year to the IHS Scholarship Program.

Health Professions Scholarship
Program Only
q Placement Update (Form IHS-856-14). Due: To the IHS
Headquarters Placement Officer within 60 days of graduation
and every 60 days thereafter until working at an approved
site as a full-time employee in a clinical position.
q Notice of Impending Graduation (Form IHS-856-15). Due: To
the IHS Scholarship Program one month prior to graduation.
q Extern Site Preference (Form IHS-856-16). Due: To the IHS
Area Coordinator the first Friday of February of the academic
year.
q Request for Extern Travel Reimbursement (Form
IHS-856-17). Due: To the IHS Area Coordinator prior to travel.
q Annual Status Report (Form IHS-856-18). Due: To the IHS
Scholarship Program prior to receiving credit for payback
activity.
q Preferred Assignment (Form IHS-856-19). Due: To the IHS
Scholarship Coordinator one month prior to graduation
q Request for Prior Approval of Deferment (Form IHS-856-20).
Due: To the IHS Scholarship Branch May 31 of the
academic year.

SECTION J: Forms
Duplicates of these forms can be found at
www.scholarship.ihs.gov.
» Lost Stipend Checks/Direct Deposit (Form IHS-856-9)
» Initial Program Progress Report (Form IHS-856-10)
» Notification of Academic Problem or Change
(Form IHS-856-11)
» Request for Tutorial Assistance (Form IHS-856-12)
» Summer School Request (Form IHS-856-13)
» Placement Update (Form IHS-856-14)
» Notice of Impending Graduation (Form IHS-856-15)
» Extern Site Preference Request (Form IHS-856-16)
» Request for Extern Travel Reimbursement
(Form IHS-856-17)
» Annual Status Report (Form IHS-856-18)
» Preferred Assignment (Form IHS-856-19)
» Request for Prior Approval of Deferment
(Form IHS-856-20)
» Federal Income Tax Withholding (Form W-4)

PUBLIC LAW 94-437 STUDENT HANDBOOK

LOST STIPEND CHECKS / DIRECT DEPOSIT

IHS-856-9

LOST STIPEND CHECK / DIRECT DEPOSIT

(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

IHS Division of Grants Operations
Grants Scholarship Coordinator
801 Thompson Avenue - Suite 450
Rockville, Maryland 20852
Attention Grants/Financial Management:
I did not receive my Electronic Transfer of Funds in the amount of $________________ for the
month __________________. I believe the ETF was not received for the following reason:
________________________________________________________________________________
_______________________________________________ ______________________ _______ __ .
Please trace and reissue as soon as possible.
Name: ___________________________________
Address: ___________________________________
___________________________________
___________________________________
___________________________________
Telephone and/or
Cell Phone Number: ___________________________________
Social Security Number: ___________________________________
EMail Address: ___________________________________

______________________________________ Signature (Do Not Print)

Please return a completed IHS-856-9 form to IHSSP, 801 Thompson Avenue Suite 450, Rockville, MD 20852.

LOST STIPEND CHECKS / DIRECT DEPOSIT

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-9

(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.

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

(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

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 Suite 450, Rockville, MD 20852.

Reviewed (IHS use only):

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK
IHS-856-10

(Rev. 5/07)

PUBLIC LAW 94-437 STUDENT HANDBOOK

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

IHS-856-11

NOTIFICATION OF ACADEMIC PROBLEM/CHANGE

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

INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU:
I AM CURRENTLY ENROLLED IN THE
MINIMUM REQUIREMENT OF 12 CREDIT
HOURS BUT AM HAVING PROBLEMS.

I HAVE BEEN PLACED ON ACADEMIC
PROBATION.

I AM A PART-TIME STUDENT CURRENTLY
ENROLLED IN AT LEAST 6 CREDIT HOURS
BUT HAVING PROBLEMS.

Previous Enrolled Credit Hours

I HAVE DROPPED COURSES WITH RECOMMENDATION AND APPROVAL OF MY
ADVISOR.

Current Enrolled Credit Hours

DESCRIPTION OF PROBLEM:

LIST BY COURSE NUMBER, TITLE, AND HOURS THE COURSES YOU ARE HAVING PROBLEMS IN:
COURSE NUMBER

TITLE

HRS.

COURSE NUMBER

TITLE

HRS.

DESCRIBE YOUR PROPOSED ACTION (i.e., obtain tutor assistance, seek no assistance and withdraw or terminate, etc.):

STUDENT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE

DATE

SCHOLARSHIP COORDINATOR’S SIGNATURE

DATE REVIEWED

BRANCH CHIEF’S SIGNATURE

DATE REVIEWED

Please return the completed IHS-856-11 form to IHSSP, 801 Thompson Avenue Suite 450, Rockville, MD 20852.

SCHOLARSHIP REPORTING REQUIREMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK
IHS-856-11

(Rev. 5/07)

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 STUDENT HANDBOOK

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 Suite 450, Rockville, MD 20852.

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 STUDENT HANDBOOK
IHS-856-12

(Rev. 5/07)

PUBLIC LAW 94-437 STUDENT HANDBOOK

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST
IHS-856-13

PUBLIC LAW 94-437 TITLE I – IHS SCHOLARSHIP PROGRAM

SUMMER SCHOOL REQUEST

(Rev. 5/07)

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

A Summer School Request must be received in the IHS Scholarship Office by April 22 of
the academic year in order for an applicant to be eligible for Summer School.

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

CIRCLE ONE: Fall Winter Spring Summer

Pre-graduate

Health Professions

CIRCLE ONE: Full-time Part-time

CLEARLY AND SPECIFICALLY DEFINE THE PURPOSE OF YOUR REQUEST FOR APPROVAL TO ATTEND
SUMMER SCHOOL:

PROPOSED SESSION(S) AND COURSE(S) (Please include all courses required)
SUMMER SESSION I DATES:

FROM

SUMMER SESSION II DATES:

FROM

COURSE NUMBER

TITLE

HOURS

YOU MUST SUBMIT DOCUMENTATION TO SUBSTANTIATE THESE COURSE REQUIREMENTS.

FUNDING REQUESTED (Must include tuition amount for each session):
TUITION
FEES
TOTAL

SUMMER SESSION I

SUMMER SESSION II

SUMMER SESSION III

APPLICANT’S SIGNATURE

DATE

ADVISOR’S SIGNATURE

DATE

SCHOLARSHIP COORDINATOR’S SIGNATURE

DATE

Please return the completed IHS-856-13 form to IHSSP,
801 Thompson Avenue Suite 450, Rockville, MD 20852.

DATE REVIEWED (IHS use only)

TUTORIAL ASSISTANCE OR SUMMER SCHOOL REQUEST

PUBLIC LAW 94-437 STUDENT HANDBOOK
IHS-856-13

(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.

PUBLIC LAW 94-437 STUDENT HANDBOOK

BREACH & DEFAULT / MONITORING & PLACEMENT

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

PLACEMENT UPDATE
SUBMITTED ON:

IHS-856-14

(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

Date/Year

Placement Officer
IHS Scholarship Branch
801 Thompson Avenue - Suite 450
Rockville, Maryland 20852
Name:
Address:
Email Address:
Telephone Number:
Social Security Number:
Health Professions Discipline:
Graduation Date:
Type of Degree:
Name of University:
OF 612 – Optional Application for Federal Employment or Commissioned Corps Application (PHS
Form 50), Health Professions Scholarship Program Service Obligation Preferred Assignment Form
(Form IHS-856-19) sent to IHSSP Placement Officer:
POSITIONS APPLIED FOR (Rejection Letters Attached):
Vacancy Announcement/Title:
Vacancy Announcement/Title:
Vacancy Announcement/Title:

Signature (Do Not Print)

Please return the completed IHS856-14 form to IHSSP, 801
Thompson Avenue Suite 450,
Rockville, MD 20852.

BREACH & DEFAULT / MONITORING & PLACEMENT

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-14

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 11 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.

PUBLIC LAW 94-437 STUDENT HANDBOOK

BREACH & DEFAULT / MONITORING & PLACEMENT

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

NOTICE OF IMPENDING GRADUATION

IHS-856-15

(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

Placement Officer
IHS Scholarship Branch
801 Thompson Avenue - Suite 450
Rockville, Maryland 20852

I will be graduating in

Month/Year

Name:
Address:
Email Address:
Telephone Number:
Social Security Number:
Health Professions Discipline:
Graduation Date:
Type of Degree:
Name of University:
Intend to Defer (Medical Students ONLY):

Signature (Do Not Print)

Please return the completed IHS-856-15 form to IHSSP, 801 Thompson Avenue Suite 450, Rockville, MD 20852.

BREACH & DEFAULT / MONITORING & PLACEMENT

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-15

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 10 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.

EXTERN PROGRAM

PUBLIC LAW 94-437 STUDENT HANDBOOK

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

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)

EXTERN PROGRAM

PUBLIC LAW 94-437 STUDENT HANDBOOK

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)

PUBLIC LAW 94-437 STUDENT HANDBOOK

SERVICE PAYBACK OBLIGATION

IHS-856-18

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

(Rev. 5/07)

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

ANNUAL STATUS REPORT

See Estimated Average Burden Time
per Response on Reverse Side

APPLICANT’S NAME
STREET ADDRESS

EMAIL ADDRESS

CITY

STATE

AREA CODE AND TELEPHONE NUMBER

ZIP CODE

SOCIAL SECURITY NUMBER

HEALTH PROFESSION DISCIPLINE:
GRADUATION DATE:
TYPE OF DEGREE CONFERRED:
NAME OF UNIVERSITY:
ASSIGNMENT LOCATION:

INDIAN HEALTH SERVICE

URBAN INDIAN HEALTH PROGRAM

PRIVATE PRACTICE

638 COMPACT OR CONTRACT

NAME OF FACILITY
STREET ADDRESS
CITY

STATE

ZIP CODE

MY CURRENT POSITION TITLE:

(ATTACH TO THIS REPORT A COPY OF YOUR PERSONNEL ORDERS OR SF-50 AND A COPY OF YOUR CURRENT POSITION DESCRIPTION.)
NON-IHS EMPLOYEES MUST

ATTACH A SUMMARY WHICH IDENTIFIES THE PURPOSE, MISSION OR NATURE

OF THE EMPLOYING ORGANIZATION AND THE POPULATION SERVED BY THE ORGANIZATION.

COMMENTS:

SCHOLARSHIP RECIPIENT’S SIGNATURE

DATE

IMMEDIATE SUPERVISOR’S SIGNATURE

DATE

SUPERVISOR’S TITLE

SUPERVISOR’S TELEPHONE NUMBER

Please return the completed IHS-856-18 form to IHSSP, 801 Thompson Avenue Suite 450, Rockville, MD 20852.

SERVICE PAYBACK OBLIGATION

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-18

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 15 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.

SERVICE PAYBACK OBLIGATION

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-19

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

(Rev. 5/07)

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

PREFERRED ASSIGNMENT

See Estimated Average Burden Time
per Response on Reverse Side

APPLICANT’S NAME
STREET ADDRESS

EMAIL ADDRESS

CITY

STATE

AREA CODE AND TELEPHONE NUMBER

ZIP CODE

SOCIAL SECURITY NUMBER

BACKGROUND
HEALTH PROFESSION DISCIPLINE:
GRADUATION DATE:
TYPE OF DEGREE CONFERRED:
NAME OF UNIVERSITY:
DESCRIBE CLEARLY AND SPECIFICALLY THE TYPE OF WORK ASSIGNMENT YOU DESIRE TO COMPLETE YOUR SERVICE OBLIGATION:

MY SERVICE OBLIGATION PERIOD CONSISTS OF (CIRCLE ONE): 1

INDICATE

BY PRIORITY THE PREFERRED

Aberdeen, SD
Albuquerque, NM
Anchorage, AK
Bemidji, MN
Billings, MT

INDICATE

YOUR PREFERRED

IHS AREA/PROGRAM
I.H.S. Headquarters
(Rockville, MD)

Nashville, TN
Navajo, AZ
Okla City, OK

IHS HOSPITAL/CLINIC

(1)

(4)

(2)

(5)

(3)

(6)

years.

LOCATION FOR PLACEMENT:

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

TO COMPLETE YOUR SERVICE OBLIGATION:

I understand that IHS officials negotiate the assignment; however, the Director, IHS has the right to make the
final decision regarding my Health Professions Section 104 Service Obligation assignment.

Applicant’s Signature

Date

Please return the completed IHS856-19 form to IHSSP, 801
Thompson Avenue Suite 450,
Rockville, MD 20852.

SERVICE PAYBACK OBLIGATION

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-19

(Rev. 5/07)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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.

DEFERMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
INDIAN HEALTH SERVICE

HEALTH PROFESSIONS SCHOLARSHIP PROGRAM

REQUEST FOR PRIOR APPROVAL OF DEFERMENT

IHS-856-20

(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

This document represents a prior request from you for the deferment of your service obligation incurred
under Section 338-A of the Public Health Service Act.
Name:
Address:

Email Address:
Daytime Telephone Number:
Social Security Number:
Postgraduate Clinical Program:
Program Director’s Name and Clinic Address:

Length of Program:
Date available for Service:
Name, address, and telephone number (other than your own) of a person through whom you may always
be reached:

Recipient’s Signature

Date

Please return the completed IHS-856-20 form to IHSSP, 801 Thompson Avenue Suite 450, Rockville, MD 20852.

DEFERMENTS

PUBLIC LAW 94-437 STUDENT HANDBOOK

IHS-856-20

(Rev. 5/07)

Form W-4 (2007)
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal income
tax from your pay. Because your tax situation
may change, you may want to refigure your
withholding each year.
Exemption from withholding. If you are
exempt, complete only lines 1, 2, 3, 4, and 7
and sign the form to validate it. Your
exemption for 2007 expires February 16, 2008.
See Pub. 505, Tax Withholding and Estimated
Tax.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $850
and includes more than $300 of unearned
income (for example, interest and dividends)
and (b) another person can claim you as a
dependent on their tax return.
Basic instructions. If you are not exempt,
complete the Personal Allowances
Worksheet below. The worksheets on page 2
adjust your withholding allowances based on

itemized deductions, certain credits,
adjustments to income, or two-earner/multiple
job situations. Complete all worksheets that
apply. However, you may claim fewer (or zero)
allowances.
Head of household. Generally, you may claim
head of household filing status on your tax
return only if you are unmarried and pay more
than 50% of the costs of keeping up a home
for yourself and your dependent(s) or other
qualifying individuals.
Tax credits. You can take projected tax
credits into account in figuring your allowable
number of withholding allowances. Credits for
child or dependent care expenses and the
child tax credit may be claimed using the
Personal Allowances Worksheet below. See
Pub. 919, How Do I Adjust My Tax
Withholding, for information on converting
your other credits into withholding allowances.
Nonwage income. If you have a large amount
of nonwage income, such as interest or
dividends, consider making estimated tax
payments using Form 1040-ES, Estimated Tax

for Individuals. Otherwise, you may owe
additional tax. If you have pension or annuity
income, see Pub. 919 to find out if you should
adjust your withholding on Form W-4 or W-4P.
Two earners/Multiple jobs. If you have a
working spouse or more than one job, figure
the total number of allowances you are entitled
to claim on all jobs using worksheets from only
one Form W-4. Your withholding usually will
be most accurate when all allowances are
claimed on the Form W-4 for the highest
paying job and zero allowances are claimed on
the others.
Nonresident alien. If you are a nonresident
alien, see the Instructions for Form 8233
before completing this Form W-4.
Check your withholding. After your Form W-4
takes effect, use Pub. 919 to see how the
dollar amount you are having withheld
compares to your projected total tax for 2007.
See Pub. 919, especially if your earnings
exceed $130,000 (Single) or $180,000
(Married).

Personal Allowances Worksheet (Keep for your records.)
A

Enter “1” for yourself if no one else can claim you as a dependent
● You are single and have only one job; or
B Enter “1” if:
● You are married, have only one job, and your spouse does not work; or
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,000 or less.





C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
C
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.)
D
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return
E
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
F
F Enter “1” if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub 972, Child Tax Credit, for more information.
● If your total income will be less than $57,000 ($85,000 if married), enter “2” for each eligible child.
● If your total income will be between $57,000 and $84,000 ($85,000 and $119,000 if married), enter “1” for each eligible
G
child plus “1” additional if you have 4 or more eligible children.
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)  H
● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
worksheets
● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs
exceed $40,000 ($25,000 if married) see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
that apply.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.



Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form

W-4

Employee’s Withholding Allowance Certificate

Department of the Treasury
Internal Revenue Service

5
6
7

OMB No. 1545-0074

Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.



Type or print your first name and middle initial.

Last name

Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. 

Single
Married
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
6
Additional amount, if any, you want withheld from each paycheck
I claim exemption from withholding for 2007, and I certify that I meet both of the following conditions for exemption.
● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here
7

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature
(Form is not valid
unless you sign it.)
8



Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date



9 Office code (optional) 10

Cat. No. 10220Q

Employer identification number (EIN)

Form

W-4

(2007)

Form W-4 (2007)

Page

Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, or claim adjustments to income on your 2007 tax return.
1 Enter an estimate of your 2007 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions. (For 2007, you may have to reduce your itemized deductions if your income
is over $156,400 ($78,200 if married filing separately). See Worksheet 2 in Pub. 919 for details.)
1 $
$10,700 if married filing jointly or qualifying widow(er)
2 Enter:
$ 7,850 if head of household
2 $
$ 5,350 if single or married filing separately
3 Subtract line 2 from line 1. If zero or less, enter “-0-”
3 $
4 Enter an estimate of your 2007 adjustments to income, including alimony, deductible IRA contributions, and student loan interest
4 $
5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 8 in Pub. 919)
5 $
6 Enter an estimate of your 2007 nonwage income (such as dividends or interest)
6 $
7 Subtract line 6 from line 5. If zero or less, enter “-0-”
7 $
8 Divide the amount on line 7 by $3,400 and enter the result here. Drop any fraction
8
9 Enter the number from the Personal Allowances Worksheet, line H, page 1
9
10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10





Two-Earners/Multiple Jobs Worksheet (See Two earners/multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $50,000 or less, do not enter more
than “3.”

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional
withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9

Enter the number from line 2 of this worksheet
4
Enter the number from line 1 of this worksheet
5
Subtract line 5 from line 4
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
Divide line 8 by the number of pay periods remaining in 2007. For example, divide by 26 if you are paid
every two weeks and you complete this form in December 2006. Enter the result here and on Form W-4,
line 6, page 1. This is the additional amount to be withheld from each paycheck

Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0
4,501
9,001
18,001
22,001
26,001
32,001
38,001
46,001
55,001
60,001
65,001
75,001
95,001
105,001
120,001

$4,500
9,000
18,000
22,000
26,000
32,000
38,000
46,000
55,000
60,000
65,000
75,000
95,000
- 105,000
- 120,000
and over

Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

If wages from LOWEST
paying job are—
$6,000
12,000
19,000
26,000
35,000
50,000
65,000
80,000
90,000
- 120,000
and over

All Others

Married Filing Jointly
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10

Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. The
Internal Revenue Code requires this information under sections 3402(f)(2)(A) and
6109 and their regulations. Failure to provide a properly completed form will
result in your being treated as a single person who claims no withholding
allowances; providing fraudulent information may also subject you to penalties.
Routine uses of this information include giving it to the Department of Justice for
civil and criminal litigation, to cities, states, and the District of Columbia for use in
administering their tax laws, and using it in the National Directory of New Hires.
We may also disclose this information to other countries under a tax treaty, to
federal and state agencies to enforce federal nontax criminal laws, or to federal
law enforcement and intelligence agencies to combat terrorism.

$
$

Table 2
All Others

$0
6,001
12,001
19,001
26,001
35,001
50,001
65,001
80,001
90,001
120,001

6
7
8

If wages from HIGHEST
paying job are—
$0
65,001
120,001
170,001
300,001

- $65,000
- 120,000
- 170,000
- 300,000
and over

If wages from HIGHEST
Enter on
line 7 above paying job are—
$510
850
950
1,120
1,190

$0
35,001
80,001
150,001
340,001

- $35,000
80,000
- 150,000
- 340,000
and over

Enter on
line 7 above
$510
850
950
1,120
1,190

You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.

SECTION K: Disclaimers

SECTION K: Disclaimers
Discrimination Prohibited
Title VI of the Civil Rights Act of 1964 states: “No person in the
United States shall, on the ground of race, color, or national
origin, be excluded from participation in, be denied the benefits
of, or be subjected to discrimination, under any program or
activity receiving federal financial assistance.”
Title IX of the Education Amendments of 1972 and its implementing regulations (45 Code of Federal Regulations, part 86)
provide that no person in the United States shall, on the basis
of sex, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal
financial assistance.
Section 504 of the Rehabilitation Act of 1973, as amended,
provides that no otherwise qualified handicapped individual
in the United States shall, solely by reason of his handicap, be
excluded from participation in, be denied the benefits of, or
be subjected to discrimination under any program or activity
receiving federal financial assistance.

Privacy Act Notice
General
This information is provided pursuant to the Privacy Act of
1974 (Public Law 93-579), December 31, 1974, for individuals
supplying information for inclusion in a system of records.

Authority
Sections 751-757 of the Public Health Service Act and Sections
102 and 104 of the Indian Health Care Improvement Act (P.L.
94-437), as amended by the Indian Health Care Amendments
of 1988, 1992, and 1996 (P.L. 100-713, P.L. 102-573 and P.L.
704-313).

Purposes and Uses
The purpose of the Indian Health Service Scholarship Programs
is to obtain health professionals to meet the staffing needs of
Indian health programs in health manpower shortage areas.
The information you supply will be used to evaluate your
qualifications and suitability for participation in the program.
Selections are made on a competitive basis. A selectee’s
application and related data are made part of the file to be
used within the Department of Health and Human Services for
record keeping and participant management while the selectee
is in the program. The information may also be disclosed
outside the Department as permitted by the Privacy Act,
including disclosures to the public as required by the Freedom
of Information Act, to the Congress, the National Archives, the
Bureau of Accounting Office, and pursuant to court order. The
name of a scholarship recipient, the professional school he or
she is attending, and the date of graduation, may be made
available to health professions associations and to groups who
have responsibility for coordinating funds paid to students from
federal and other sources, and to individuals and organizations
deemed qualified by the Secretary to carry out specific research
solely for the purpose of carrying out such research. You are
asked to provide your Social Security Number on a voluntary
basis. Should you not provide this information and you are
awarded a scholarship, this number will be required later for
purposes of payroll and payments to you of Scholarship benefits.

Effects of Nondisclosure
Disclosure of the information sought is voluntary; however, if
not submitted, except for the Social Security number, an application will be considered incomplete and chances for selection
are diminished.

Reporting Fraud and Abuse
The General Accounting Office maintains a toll-free number,
1(800) 424-5454, for receiving information concerning fraud,
waste and abuse under grants and cooperative agreements.
Such reports are kept confidential and callers may decline to
give their names if they choose to remain anonymous.
The Health and Human Services (HHS) Inspector General
maintains a toll-free hotline for receiving information
concerning fraud, waste or abuse under grants and cooperative
agreements. Such reports are kept confidential and callers
may decline to give their names if they choose to remain
anonymous.
For contacting the HHS Inspector General:
Toll free Hotline: 1(800) 447-8477
Outside Maryland: 1(800) 368-5779
Mailing address: Department of Health and Human Services
Office of the Inspector General
Box 23489
Washington, DC 20007
Email: HHStips@oig.hhs.gov
Web site: oig.hhs.gov/hotline.html

File Type	application/pdf
File Modified	2007-10-15
File Created	2007-10-09