ihs form 856-4

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

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

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
FACULTY/EMPLOYER EVALUATION
STUDENT’S NAME

REGARDING

See Estimated Average Burden Time
per Response on Reverse Side.

SOCIAL SECURITY NUMBER

CAREER CATEGORY

EMAIL ADDRESS

The student identified above is applying to receive an Indian Health Service (IHS) Scholarship. The information on this
form is requested pursuant to Section 751-756 of the Public Health Service Act, as amended, and applicable program
regulations which provide that, in evaluating and selecting individuals for scholarships, consideration will be given to
faculty or employer recommendations.
The information provided on this form is treated as confidential and may only be disclosed outside the Department of
Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and
conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.
PLEASE RETURN COMPLETED FORM TO APPLICANT

1. How do you rate the educational/work achievement of this applicant? (Please provide written comments.)
5OUTSTANDING

4ABOVE AVERAGE

3AVERAGE

2BELOW AVERAGE

0POOR

2. How do you rate the applicant’s relationships with other people?
Consider such things as ability to work and get along with others. (Please provide written comments.)
5OUTSTANDING

4ABOVE AVERAGE

3AVERAGE

2BELOW AVERAGE

0POOR

3. Based on this applicant’s personal, emotional, ethical attributes, how do you rate his/her over-all potential for
the practice of primary health care, especially in a health manpower shortage area?
(Please provide written comments.)
54320OUTSTANDING
ABOVE AVERAGE
AVERAGE
BELOW AVERAGE
POOR
Please provide written comments:

Type of work:
Length of time known:

Statement of Conflict of Interest: I certify I am not related to applicant by blood or marriage.
NAME (Print or type)

TITLE OF POSITION

IHS-856-4 (5/07)

SIGNATURE

DATE

PLACE OF EMPLOYMENT

EF

ATTACHMENT II (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 50 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 display 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, ATTN: PRA (0917-0006).