Form IHS-856-9 Notification of Academic Problem

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

NOTIFICATION OF ACADEMIC PROBLEM
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

SCHOLARSHIP PROGRAM:

Home

EMAIL ADDRESS

Preparatory

Pre-Graduate

Enrollment Status:

Fall

Winter

Spring

Semester

Quarter

Trimester

Full-time

Part-time

Health Professions
Summer

INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU:
I am having problems with my courses.

I am considering withdrawing from school.

My advisor has recommended that I
drop one or more of my courses.

I have been dismissed from school.

Current Enrolled Credit Hours

Proposed 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., seek no assistance and withdraw or terminate, plan to repeat course(s) during summer school, etc.):

Required signature on back of this form
IHS-856-9

EF

Recipient’s SIGNATURE

DATE

Advisor/Counselor NAME (Print)

Advisor/Counselor Signature



DATE

Position Title

PHONE: CELL

OFFICE

Return to:
IHS Scholarship Program
Attn: Program Analyst
801 Thompson Ave., Suite 120
Rockville, MD 20852

Reviewed (IHS use only): 
Analyst, Branch Chief or Designee

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, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.