Application for Participation in the IHS Scholarship Program

ICR 201609-0917-001

OMB: 0917-0006

Federal Form Document

ICR Details
0917-0006 201609-0917-001
Historical Active 201308-0917-001
HHS/IHS 19731
Application for Participation in the IHS Scholarship Program
Revision of a currently approved collection   No
Regular
Approved with change 03/24/2017
Retrieve Notice of Action (NOA) 09/22/2016
  Inventory as of this Action Requested Previously Approved
03/31/2020 36 Months From Approved 03/31/2017
12,580 0 12,580
4,340 0 4,340
0 0 0

Program forms collect information used to solicit, process and award scholarships, monitor academic performance and place awardees in payback sites. The data is needed to plan, manage, direct, operate and evaluate the IHSA Scholarship program.

PL: Pub.L. 94 - 437 522 Name of Law: Indian Health Care Improvement
  
None

Not associated with rulemaking

  81 FR 44030 07/06/2016
81 FR 60368 09/01/2016
No

22
IC Title Form No. Form Name
Delinquent Federal Debt IHS-856-5 Delinquent Federal Debt
Verification of Acceptance or Decline of Award IHS-856-7 Verification of Acceptance or Decline of Award
Recipient's Initial Program Progress Report ihs-856-8 Recipient's Initial Program Progress Report
Notification of Academic Problem IHS-856-9 Notification of Academic Problem
Change of Status IHS-856-10 Change of Status
Request for Approval of Deferment HS-856-11 Request for Approval of Deferment
Preferred Placement IHS-856-12 Preferred Placement
Notice of Impending Graduation IHS-856-13 Notice of Impending Graduation
Notification of Deferment Program IHS-856-14 Notification of Deferment Program
Placement Update IHS-856-15 Placement Update
Annual Status Report IHS-856-16 Annual Status Report
Extern Site Preference Request IHS-856-17 Extern Site Preference Request
Request for Extern Travel Reimbursement IHS-856-18 Request for Extern Travel Reimbursement
Lost Stipend Payment IHS-856-19 Lost Stipend Payment
Summer School Request IHS-856-21 Summer School Request
Change of Name or Address IHS-856-22 Change of Name or Address
Request for Credit Validation IHS-856-23 Request for Credit Validation
Faculty/Advisor Evaluation IHS-856-24 Faculty-Advisor Evaluation
Scholarship Program Agreement IHS-817 Scholarship Program Agreement
Health Professions Contract IHS 818 Contract
Faculty/Employer Evaluation IHS-856-3 Faculty/Employer Evaluation
Course Curriculum Verification IHS-856-6 Course Curriculum Verification

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 12,580 12,580 0 0 0 0
Annual Time Burden (Hours) 4,340 4,340 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$107,713
No
Yes
No
No
No
Uncollected
Evonne Bennett-Barnes 301 443-4750 evonne.bennett-barnes@ihs.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/22/2016


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