Form IHS-856-4 Narrative Statements

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.

NARRATIVE STATEMENTS
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

IHS AREA OFFICE

EMAIL ADDRESS

Explain why you are requesting this scholarship**

State your career goals**

Explain how these goals will help to meet the health needs of the Indian people**

**If more space is required, use additional sheets of 8 1/2” x 11” paper. Write your name and social security number on each additional sheet of paper. Securely attach
additional sheets to this form.
IHS-856-4

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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.