Form IHS-856-14 Notification of Deferment Program

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

Notification of Deferment Program
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

This document notifies the IHS Scholarship Program of your selected deferment program,
if approved this will delay the service obligation incurred under Section 338-A of the Public Health Service Act.

Post-Graduate Clinical Training Program:
Program Director (Name):
Program Address:

City

Phone

LENGTH OF PROGRAM:

State

Zip Code

Email Address

Start Date

End Date

Date available to begin service obligation:
Emergency Contact Information
NAME

PHONE: CELL

ADDRESS

CITY

STATE

RECIPIENT’S SIGNATURE

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ZIP CODE

DATE

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
IHS-856-14

Approved (IHS use only):
EF

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.