Form IHS-856-17 Extern Site Preference Request

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

EXTERN SITE PREFERENCE REQUEST
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

I am applying to:

Civil Service

Home

EMAIL ADDRESS

COSTEP Program

Are you an IHS Scholarship Program recipient?

Yes

No
CURRENT GPA:

PROJECTED GRADUATION DATE:
College/University:
DATES AVAILABLE FOR EXTERN ASSIGNMENT: From

To

DESCRIBE THE TYPE OF EXTERN ASSIGNMENT YOU DESIRE:

EXTERN SITE PREFERENCE
INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR Extern Assignment:
Aberdeen

Billings

Okla City

Albuquerque

California

Phoenix

Anchorage

Nashville

Portland

Bemidji

Navajo

Tucson

INDICATE YOUR PREFERRED IHS OR TRIBAL HOSPITAL/CLINIC FOR EXTERNSHIP:
(1)

(2)

(3)

(4)

COMMENTS:

SIGNATURE

DATE

Return the completed form to the Area Scholarship Coordinator at the IHS Area Office
where you are requesting your extern assignment (visit www.scholarship.ihs.gov for the most up-to-date contact information).

Reviewed (IHS use only): 
Extern Coordinator, Branch Chief or Designee
IHS-856-17

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.