Form IHS-856-20 Request for Tutorial Assistance

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 TUTORIAL ASSISTANCE
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

SCHOLARSHIP PROGRAM:

Home

EMAIL ADDRESS

Preparatory

Pre-Graduate

Enrollment Status:

Fall

Winter

Spring

Semester

Quarter

Trimester

Full-time

Part-time

Health Professions
Summer

I AM SEEKING TUTORIAL ASSISTANCE FOR THE FOLLOWING COURSE(S):
COURSE NUMBER

COURSE TITLE

HRS.

DESCRIPTION OF ACADEMIC PROBLEM(S)/JUSTIFICATION OF ASSISTANCE:

TUTORIAL REQUEST
(Must include all tutors)
NAME(S) OF TUTOR(S)

NUMBER OF HOURS

RATES PER HOUR

SUBTOTAL COST

NUMBER OF HOURS

RATES PER HOUR

SUBTOTAL COST

TOTAL COST:
Required signature on back of this form
IHS-856-20

EF

RECIPIENT’S SIGNATURE

DATE

ADVISOR’S NAME (Print)

DATE

ADVISOR’S SIGNATURE



PHONE:

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

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.