Form IHS-856-3 Faculty/Employer Evaluation

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.

FACULTY/EMPLOYER EVALUATION
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

IHS AREA OFFICE

EMAIL ADDRESS

The student identified above is applying to receive an Indian Health Service (IHS) scholarship. The information on
this form is requested pursuant to Section 751-756 of the Public Health Service Act, as amended, and applicable
program regulations which provide that, in evaluating and selecting individuals for scholarships, consideration will be
given to faculty or employer recommendations.
The information provided on this form is treated as confidential and may only be disclosed outside the Department of
Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and
conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.
PLEASE RETURN COMPLETED FORM TO APPLICANT
1. How do you rate the educational/work achievement of this applicant?
5 - OUTSTANDING
4 - ABOVE AVERAGE
3 - AVERAGE

2-

BELOW AVERAGE

0-

POOR

Comments:

2. H
 ow do you rate the applicant’s relationships with other people? Consider such things as ability to work and get
along with others.
4 - ABOVE AVERAGE
3 - AVERAGE
2 - BELOW AVERAGE
0 - POOR
5 - OUTSTANDING
Comments:

3. B
 ased on this applicant’s personal, emotional and ethical attributes, how do you rate his/her overall potential for the
practice of primary health care, especially in a Health Professional Shortage Area (HPSA)?
5 - OUTSTANDING
4 - ABOVE AVERAGE
3 - AVERAGE
2 - BELOW AVERAGE
0 - POOR
Comments:

4. Type of work (applicant):
5. Length of time known:
Statement of Conflict of Interest: I certify I am not related to applicant by blood or marriage.
I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false
representation is sufficient cause for rejection of this application.
NAME (Print or type)

POSITION TITLE (Required)

SIGNATURE

IHS-856-3

PLACE OF EMPLOYMENT (Required)

DATE

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 50 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.