Supporting_Statement_for_OMB_No__0917-0006 -Final 3.24.17

Supporting Statement for IHS Scholarship Program Application

(OMB No. 0917-0006)

A. JUSTIFICATION

l. Circumstances Making the Collection of Information Necessary:

The Indian Health Service (IHS) is requesting an extension of the currently approved information collection activity, titled "IHS Scholarship Program Application” (OMB No. 0917-0006).

The IHS Scholarship Program offers qualified American Indian and Alaska Native health profession students a unique opportunity to establish an educational foundation as they prepare to pursue a career in Indian health. Each scholarship (Preparatory, Pre-Graduate and health professions) is defined by applicant and degree program eligibility and provides generous financial aid packages (information available at www.ihs.gov/scholarship). The ultimate goal of the program is to develop health care providers and the next leaders of Indian health communities. Since IHS began providing scholarship support to American Indian and Alaska Native students to pursue health profession careers in 1978, the program has grown to support, educate and place health care professionals within medically underserved Indian health programs throughout the continental United States and Alaska. Today, nearly 7,000 American Indian and Alaska Native students have received scholarship awards and many have committed to serving their health profession careers at IHS; some have even returned to serve their own Tribal communities.

The IHS Scholarship Program (IHSSP) utilizes an electronic system thereby reducing the number of supplemental paper forms and aims to minimize an applicant’s time (i.e. burden hours). The following forms can be found on the IHSSP Website, at: www.ihs.gov/scholarship/applynow. This page is also used to solicit and process program applications as well as monitor scholars during their in-school, in-deferment and in-service periods: IHS-856-3, IHS-856-5 through 856-19, IHS 856-21 through 856-24, IHS- 817 and IHS- 818.

This information is collected under the Indian Health Care Improvement Act, Public Law 94-437, as amended, which authorizes the IHS administration of the Health Professions Preparatory Scholarship Program for Indians, the Health Professions Pre-graduate Scholarship Program, and the Health Professions Scholarship Program. These programs provide funding to train the health professional personnel necessary to staff IHS health programs and other health programs serving the American Indian and Alaska Native (AI/AN) people in occupational categories and geographic locations where there are health manpower shortages.

2. Purpose and Use of Information Collection:

The information collection is used to plan, manage, direct, operate and evaluate the agency's scholarship programs. The forms discussed below are used to solicit and process program applications.

1. IHS Scholarship Program e-Application Handbook

This IHSSP e-Application Handbook provides an overview of the scholarship programs, eligibility requirements, selection criteria and ranking procedures for recipients and contains the application instructions. The application forms that need to be completed and submitted by all program applicants can be found on the IHSSP Website, at: www.ihs.gov/scholarship/applynow.

Form IHS-856, “Application for Participation in the Indian Health Service Scholarship Program” has been replaced with an online e-Application tool. The e-Application must be completed by each applicant. The information provided from this e-application is used to establish a demographic and educational profile of each applicant and includes: contact information, type of scholarship, health career, date of graduation, Tribal affiliation, full-time/part-time status, etc. This information is entered directly and automatically into the IHSSP’s scholarship management information system and provides a base for the rating/ranking and eligibility procedures used to make an award.

Form IHS-856-2, “Application Checklist” has been replaced with an online e-Checklist which is automatically generated based on the information provided by the applicant. This e-Checklist becomes a part of the printed e-Application, once the application is submitted by the applicant for funding consideration. The e-Application with e-Checklist must be printed and signed/dated by the applicant and submitted to the IHSSP along with all other required forms and supporting documentation in order for their application to be considered complete and eligible for funding.

Form IHS-856-3, “Faculty/Employer Evaluation,” collects faculty and/or employer evaluation of the applicant. The information is used as part of the applicant rating process.

Form IHS-856-4, “Narrative Statements” has been replaced by an e-Narrative, unlimited text field, within the e-Application tool. The applicant must provide a written narrative response to three standard questions. Responses are used as part of the applicant rating process.

Form IHS-856-5, “Delinquent Federal Debt,” is used by the applicant to identify and certify any delinquent Federal debt.

Form IHS-856-6, “Course Curriculum Verification.” This form identifies and verifies the school, course number(s), course title(s) and number of credit hours in which the applicant is enrolled.

Form IHS-856-7, “Verification of Acceptance or Decline of Award,” is completed by an applicant after they are notified that they have been awarded a scholarship. Before funds can be obligated, the successful applicant must complete this required form to accept or decline the offer of an IHS Scholarship.

Form IHS-815, “Acknowledgement of Receipt of Application” has been replaced with an automated electronic notification system which apprises each applicant of the status of their application at each step of the IHSSP review process.

.

Form IHS-817, “Health Professions Preparatory and Pre-graduate Education Scholarship Program Agreement - School Year 2017 to 2018,” is signed by Preparatory (Section 103) and Pre-graduate (Section 103P) applicants to indicate agreement to stated terms and conditions as participants. There is no service payback obligation in this agreement.

Form IHS- 818, “Indian Health Scholarship Program Health Professions Contract- School Year 2017 to 2018.” Health Professions (Section 104) applicants sign this contract thereby agreeing to a period of obligated service equal to one year for each year of funding, with a minimum two-year service obligation. Terms and conditions are detailed on this form.

B. Indian Health Service Scholarship Program e-Student Handbook

Scholarship recipients have access to the latest e-Student Handbook online at the IHSSP Website, www.ihs.gov/scholarship which contains information about the different IHSSP funding programs, and related forms, such as: how to maintain eligibility; how to apply for scholarship extension; what they must do if matriculating from a Preparatory or Pre-graduate degree track to a Health Professions degree track; who is eligible for service deferment; how/when to apply for service deferment; service placement and reporting requirements. The forms listed below, are used during the in-school, in-deferment and in-service periods.

Form IHS-856-8, “Recipient's Initial Program Progress Report,” is used to identify the courses in which a student is enrolled and verify that the student is enrolled in either a full-time or part-time course load for the semester/quarter/trimester.

Form IHS-856-9, “Notification of Academic Problem,” is completed by students having academic problem(s) who are placed on academic probation, or who fall below the minimum full-time or part-time credit hours. The notice alerts IHSSP staff of students experiencing academic difficulty and provides an opportunity to offer appropriate intervention to assist these students to succeed.

Form IHS-856-10, “Change of Status,” provides scholarship recipients and IHSSP staff a mechanism to officially document, and have on file, any change of status as identified in the e-Student Handbook found on the IHSSP Website, www.ihs.gov/scholarship, that could have an effect on a recipient’s scholarship status. This form is due immediately if the recipient is expecting a change of enrollment which will affect their scholarship program status.

Form IHS-856-11, “Request for Approval of Deferment,” is completed by graduating scholarship recipients requesting deferment of their service obligation to attend post-graduate training. The “Request for Approval of Deferment” form requires scholarship recipients to submit this form prior to the beginning of their final year in school if they are seeking deferment of their service obligation with the IHSSP in order to enroll in a post-graduate clinical training program. This information provided by the recipient indicates the type of program(s) where they will be submitting an application. This allows IHSSP staff the opportunity to: review a recipient’s identified post-graduate clinical training program(s); identify if the program(s) is permitted under IHSSP policies and procedures; provide the recipient with an Approval/Denial letter before December 31; and have the form on file when the recipient notifies the IHSSP of their program selection by May 31 of their final year in school.

Form IHS-856-12, “Preferred Placement,” is completed by graduating Health Professions Scholarship Program (Section 104) recipients and is used to identify their preferred payback sites. The IHSSP staff use this information to aide in the placement process of these graduates.

Form IHS-856-13, “Notice of Impending Graduation,” is completed by graduating Health Professions (Section 104) Scholarship Program recipients who will be graduating from their degree program. This form is used to monitor the student's progress towards placement in a position that will fulfill the recipient's mandatory service obligation.

Form IHS-856-14, “Notification of Deferment Program,” is completed by graduating Health Professions Scholarship Program recipients who are required/ allowed to perform post-graduate clinical training to become licensed/ specialized in their professions. It serves to notify their IHSSP analyst of where the recipient has been accepted and intends to begin their post-graduate clinical training. It provides the contact information for the recipient’s post-graduate training site and supervisor/advisor: name, title, address, and phone number.

Form IHS-856-15, “Placement Update,” is used to monitor the placement process of graduating Health Professions Scholarship Program recipients to fulfill their mandatory service obligation.

Form IHS-856-16, “Annual Status Report,” is used by the Health Professions Scholarship Program recipients who have graduated from their degree program and are either in approved deferment of their service to obtain post-graduate training/ licensure or working at an approved service payback site. This form verifies that the recipient is either successfully continuing with their post-graduate training or working at an approved payback site/position and fulfilling their service obligation requirement.

Form IHS-856-17, “Extern Site Preference Request,” is completed by those students requesting temporary employment within the IHS under the Agency's Scholarship Extern Program and provides an opportunity for the student to request their preferred work site.

Form IHS-856-18, “Request for Extern Travel Reimbursement,” is completed by students requesting travel reimbursement for one round trip to the extern site.

Form IHS-856-19, “Lost Stipend Payment” is used by scholarship recipients to initiate tracing action on an electric funds transfer (student stipend) that was not received.

Form IHS-856-20, “Request for Tutorial Assistance” is no longer being used by the IHSSP. A lump sum payment is automatically given to every scholarship recipient at the beginning of each award year, as part of their Other-Related-Costs payment. In this way the funds are immediately available to the scholarship recipient to pay for tutoring as academic difficulties arise or for licensure preparatory courses, prior to completing their programs of study.

Form IHS-856-21, “Summer School Request,” is used by students requesting to attend summer school. The form identifies the summer session dates, enrolled courses and the funding being requested to cover the cost of tuition and applicable fees. The Summer School Request form provides information regarding the recipient’s enrollment in a year-round curriculum vs. coursework which must be repeated in order for the recipient to progress in their program of study. It is an essential document for IHSSP budget purposes.

Form IHS-856-22, “Change of Name or Address,” is used by applicants and recipients to communicate name and/or address changes to IHSSP staff and becomes an official document in the recipient’s file, documenting a recipient’s name (e.g., via marriage or divorce) or address change. Requests for a change in name must be accompanied by a legal document (e.g., marriage certificate or divorce decree showing the legal change of name). This form should be submitted immediately to IHSSP staff to update a recipient’s personal information in the scholarship program database.

Form IHS-856-23, “Request for Credit Validation,” provides scholarship recipients and IHSSP staff an avenue to officially document and have on file any recipient request to grant the release of pertinent information from their file to credit card companies, banks, etc.

Form IHS-856-24, “Faculty/Advisor Evaluation” is submitted by current scholarship recipients in the same manner as new applicants use the Faculty/Employer Evaluation form during the new scholarship application process, however, it is intended only for recipients who are transferring schools, seeking dual enrollment or requesting a change in career category. This form must be submitted with a recipient’s continuation application by February 28 or with a Change of Status form should they

decide to transfer or seek dual enrollment during the academic year when the

application cycle is not open.

3. Use of Improved Information Technology and Burden Reduction:

Automated information technology is utilized, as appropriate, for processing the IHSSP applications. The IHSSP has developed and implemented an online application process, which began in 2008 and has undergone significant expansion and refinement during subsequent years. Students are able to utilize the Internet to apply for a scholarship. Students complete and submit the online application which incorporates the content from several previously used IHSSP forms, thus reducing the number of “hardcopy” forms needed by the IHSSP to process these applications and the investment (time and money) required to reproduce these forms. Forms that have not yet been incorporated into the online e-Application process are available online at www.ihs.gov/scholarship, for the student to download and complete.

4. Efforts to Identify Duplication and Use of Similar Information:

No similar information is collected from this population.

5. Impact on Small Businesses or Other Small Entities:

An IHS scholarship applicant may send the Faculty/Employer Evaluation Form (Form IHS-856-3), to a current or former employer who is a small business or other small entity. It is estimated that this form will require less than an hour to complete. The items of information requested are the minimum required to permit IHS staff to make an informed decision concerning the suitability of the IHS scholarship applicant seeking an award.

6. Consequences of Collecting the Information Less Frequently:

A scholarship application for this program must be completed prior to the beginning of each academic school year. If this information collection were to be conducted less frequently, it would not be possible to determine eligibility or to track the scholastic progress of the scholarship recipients.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5:

The collection of information will be consistent with 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice/Outside Consultation Agency:

The 60 Day Federal Register notice was published in the Federal Register (81 Vol. FR 44030) on July 06, 2016, to solicit public comments on the information collection prior to submission to OMB, as required by 44 U.S.C. § 3506(c) (2) (A). IHS received no comments.

9. Explanation of Any Payment/Gift to Respondents:

No payment is provided to respondents for providing the requested information. Successful applicants may receive a benefit in the form of an IHS Scholarship.

10. Assurance of Confidentiality Provided to Respondents:

Data gathered on this application form constitutes a system of records as defined under the Privacy Act of 1974. The systems notice for the IHSSP is 09-17-0002, IHS Scholarship Programs, HHS/IHS/OHP. The information collected through use of the IHSSP application, as well as handling and storage of this information, will be in compliance with the Privacy Act. A Privacy Act Notice, which describes; the authority for collecting the information; the purposes for which the information is collected; routine use disclosures which may be made of the information collected; and the necessity of reporting to receive scholarship award consideration is contained in the IHSSP’s “e-Student Handbook,” and the “e-Application Handbook” found online at www.ihs.gov/scholarship.

11. Justification for Sensitive Questions:

There are no questions on the application form which are considered to be sensitive.

1. Estimates of Annualized Burden Hours (Total Hours and Wages):

12a. Estimate of Total Annual Cost Burden to Respondents (Hours):

The annual burden hours figures include the Number of Respondents (based on number of applicants starting an application in FY 2015), Responses per Respondent (based on number of responses per applicant required to complete application), Total Annual Responses (based on Number of Respondents multiplied by the Responses per Respondents) and the Burden Hours per Response (based on the amount of time it took a sample of students to complete the form).

Annual Burden Hours

*For ease of understanding, burden hours per response are also provided in minutes.

Data Collection Instrument(s)	Number of respondents	Responses per respondents	Total annual response	Burden hour per response*	Annual burden hours
Faculty/Employer Evaluation (IHS-856-3)	1500	2	3000	0.42 (25 min)	1250
Delinquent Federal Debt (IHS-856-5)	1500	1	1500	0.13 (8 min)	200
Course Curriculum Verification (IHS-856-6)	1500	1	1500	0.70 (42 min)	1050
Verification of Acceptance or Decline of Award (IHS-856-7)	350	1	350	0.13 (8 min)	47
Recipient’s Initial Program Progress Report (IHS-856-8)	1200	1	1200	0.13 (8 min)	160
Notification of Academic Problem (IHS-856-9)	50	1	50	0.13 (8 min)	7
Change of Status (IHS- 856-10)	50	1	50	0.45 (25 min)	21
Request for Approval of Deferment (IHS-856-11)	20	1	20	0.13 (8 min)	3
Preferred Placement (IHS-856-12)	150	1	150	0.50 (30 min)	75
Notice of Impending Graduation (IHS-856-13)	120	1	120	0.17 (10 min)	20
Notification of Deferment Program (IHS-856-14)	20	1	20	0.13 (8 min)	3
Placement Update (IHS-856-15)	120	1	120	0.18 (11 min)	22
Annual Status Report (IHS-856-16)	200	1	200	0.25 (15 min)	50
Extern Site Preference Request (IHS-856-17)	300	1	300	0.13 (8 min)	40
Request for Extern Travel Reimbursement (IHS-856-18)	150	1	150	\ 0.10 (6 min)	15
Lost stipend Payment (IHS-856-19	50	1	50	0.13 (8 min)	7
Summer School Request (IHS-856-21)	100	1	100	0.10 (6 min)	10
Change of Name or Address (IHS-856-22)	20	1	20	0.13 (8 min)	3
Request for Credit Validation (IHS-856-23)	30	1	30	0.10 (6 min)	3
Faculty/Advisor Evaluation (IHS-856-24)	1500	2	3000	0.42 (25 min)	1250
Scholarship Program Agreement (IHS-817)	175	1	175	0.16 (10 min)	29
Health Professions Contract (IHS-818)	225	1	225	0.16 (10 min)	38
Total		---	12,330	---	4,303

*For ease of understanding, burden hours per response are also provided in minutes.

12b. Estimate of Total Annual Cost Burden to Respondents (Wages):

There is no direct cost to respondents other than their time to voluntarily complete

the forms and submit them for consideration. The estimated cost in time to respondents, as a group, is $45,009 [4,303 burden hours x $10.46 per burden hour (2013 GS-3 base pay rate) = $45,009].

12. Estimate of Other Total Annual Burden to Respondents or

Recordkeepers/Capitol Costs:

There are no other costs to the respondents associated with this information

collection.

14. Total Cost to the Federal Government:

The cost to the Federal Government related to IHS Scholarship Program (IHSSP) staff payroll for processing incoming forms and applications totals $55,680 / yr [4 - GS-12 employees (4 x $29 per hour = $116) x 8 hrs/ day x 60 days per year]. The average cost of maintaining the IHSSP website, including Update/Upload of forms and site content for the IHSSP is $17,773.00/ yr. The cost of the contractor Help Desk Support for the IHSSP Online Application system is $26,004.00/ yr. The cost of Running the Online Application system and maintaining the database is borne by the IHS-Office of Information Technology and is estimated at $8,256. There is no annual cost to the Federal Government for printing the e-Application Handbook, e-Student Handbook or IHSSP forms used by applicants and recipients, because these resources are made available online at www.ihs.gov/scholarships and are no longer printed and mailed to students requesting applications or to IHSSP recipients. Therefore, the total cost to the Federal Government for this Information Collection Request activity is $107,713 per yr.

15. Explanation for Program Changes or Adjustments:

The program change (i.e., decrease in the burden hours by 25 hours) is due to a decrease in the number of scholars completing forms IHS-856-7, IHS-856-13, and IHS-856-15. While IHS has incorporated some additional forms in the online application process (i.e., forms IHS-856-5 and IHS-856-6) the applicants still need to provide this information as part of the online, electronic application.

16. Plans for Tabulations and Publication and Project Time Schedule:

There are no plans for the tabulation, statistical analysis and publication of information collected.

17. Reason(s) Display of OMB Expiration Date is Appropriate:

OMB information will be displayed on information collection forms accordingly.

18. Exceptions to Certification for Paperwork Reduction Act Submissions:

None.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

This information collection activity will not employ sampling to select respondents (IHSSP applicants).

16