Form IHS-856-18 Request for Extern Travel Reimbursement

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.

REQUEST FOR EXTERN TRAVEL REIMBURSEMENT
Travel expenses are paid according to Travel and Transportation Allowances in the Joint Travel Regulations and Federal Travel Regulations.
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

BELOW IS ESTIMATED EXPENSE OF PROPOSED TRAVEL

PURPOSE OF TRAVEL:

DATES OF TRAVEL:

Travel Destination: From

To

Miles (by car):

TRAVEL DAYS:

Airfare (coach only):

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-856-18

EF

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