Form IHS-856-10 Change of Status

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.

Change of STATUS
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: Cell

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU:
School Transfer/Dual Enrollment
Reason for Transfer/Dual Enrollment:
 New school has an accredited program for my career category
 Second campus offers courses necessary to obtain my degree
 Personal/Family hardship
COMMENTS:
See Change of Status section of the Student Handbook for the IHS Scholarship Program policies and procedures that must be followed
to complete a school transfer/dual enrollment.

Change in Graduation Date
Current Graduation Date:
Proposed New Graduation Date:
Explain your reason(s) for changing your graduation date:

See Change of Status section of the Student Handbook for the IHS Scholarship Program policies and procedures related to changing
your graduation date.

IHS Scholarship Program Change
Current Scholarship Program:
New Scholarship Program:
Explain your reason(s) for changing your scholarship program:

See Change of Status section of the Student Handbook for the IHS Scholarship Program policies and procedures related to changing
your scholarship program.

Continues on back
IHS-856-10

EF

Leave of Absence (LOA)
Date LOA WILL END:

Date LOA will begin:

Explain your reason(s) for requesting an LOA:

Note: You may not request an LOA during your first year of scholarship funding.
See Change of Status section of the Student Handbook for the IHS Scholarship Program policies and procedures related to requesting an LOA.

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

Approved (IHS use only):

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 25 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.