Form IHS-856-12 Preferred Placement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

PREFERRED PLACEMENT
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

BACKGROUND
CAREER CATEGORY:
GRADUATION DATE:
DEGREE OBTAINED:
COLLEGE/UNIVERSITY:
DESCRIBE CLEARLY AND SPECIFICALLY THE TYPE OF WORK ASSIGNMENT YOU DESIRE TO COMPLETE YOUR
SERVICE OBLIGATION:
MY SERVICE OBLIGATION IS FOR A PERIOD OF (Circle one):

2

3

4

years.

INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR PLACEMENT:
Aberdeen

Billings

Okla City

Albuquerque

California

Phoenix

Anchorage

Nashville

Portland

Bemidji

Navajo

Tucson

INDICATE YOUR PREFERRED IHS, Tribal or Urban HOSPITAL/CLINIC TO COMPLETE YOUR SERVICE OBLIGATION:
(1)

(4)

(2)

(5)

(3)

(6)

I understand that IHS Scholarship Program officials must approve my placement and position at my chosen Indian health facility. The Director, IHS has
the right to make the final decision regarding placement if I have not selected an Indian health facility at which to fulfill my contractual service obligation
within 90 days of graduation or completion of training.
RECIPIENT’S SIGNATURE

DATE

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
IHS-856-12

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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.