Form 0917-0014 Educational and Professional Background

IHS Loan Repayment Application - Educational and Professional Background

U.S. Department of Health and Human Services

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   General Applicant Information   

Educational and Professional Background   Financial Information   Affidavit/Sample LRP   Finish

  Required Documents
Form Approved, OMB Approval No. 0917-0014, Expiration Date: 07/31/15

  Complete Your Form

Indian Health Careers

Educational and Professional Background

LRP Basics

This section is to be completed by graduates only and details your educational and practice experience, if applicable. Information covered includes
training and graduate programs, practice experience and licensing.

Policies
and Procedures 

*indicates required field

Site Scores

*Name of Professional School

Resources

*School Address   

FAQs
*Degree Obtained

   *Graduate Year

Contact the LRP Office
Have you completed a residency or graduate program?
(MD, DO, DDS, PedNP, PA, etc.)  
Residency/Graduate Program Information  Help
Year residency or program was/will be completed
Residency or Program Name
Specialty

   Board Certified

Year re-certified (if applicable)

    Board Eligible

  Help

   Sub-specialty (if applicable)

Practice Experience
If applicable, describe your practice experience over the last five years (Include location, nature of population served, number of specialties in the
practice, hospital affiliations and allocation of clinical practice time to FP/GP, INT, OB/GYN, PED, PSYCH, ER).

Current Practice Time Allocation
Please enter your practice time allocation at your current Indian Health Program job site. Enter the current percent of your practice time that is officebased and hospital/clinic-based and/or spent in administration and teaching (numbers only).
Office-based

%    Clinic-based

%    Administration

%    Teaching

%

Last Work Site
For the last site at which you worked:  Help
Name of Site Director or Official

https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=edu[4/2/2015 3:25:26 PM]

   Your Job Title

IHS Loan Repayment Application - Educational and Professional Background
Address

   Phone (

)

-

ext:

Professional References (this information will be kept confidential)
Reference 1
Name
Address

   Position or Title
   Phone (

)

-

ext:

Reference 2
Name
Address

   Position or Title
   Phone (

)

-

ext:

Reference 3
Name

   Position or Title

Address

   Phone (

)

-

ext:

I certify that the information given in this application is accurate to the best of my knowledge and belief. I understand that it may be investigated
and that any willfully false representation is sufficient cause for rejection of this application; and if awarded a loan repayment, that I am liable for
repayment of all awarded funds and, further, that any false statement herein may be punished as a felony under US Code Title 18 Section 1001.
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Estimated Average Burden Time to Complete the Application Form: Public reporting burden for this collection of information is estimated to vary from 60 to 120 minutes per response with an average
of 90 minutes per response, including the 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, Reports Clearance Officer, Attn: PRA
(0917-0014), 12300 Twinbrook Parkway, Suite 450, Rockville, MD 20852. Do not mail completed forms to the above address.

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Indian Health Service (HQ) - The Reyes Building, 801 Thompson Avenue, Ste. 400 - Rockville, MD 20852

https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=edu[4/2/2015 3:25:26 PM]