Form IHS-856-6 Course Curriculum Verification

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.

COURSE CURRICULUM VERIFICATION
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

IHS AREA OFFICE

Are you applying as a:  New Applicant

EMAIL ADDRESS

Continuing Applicant

THIS FORM MUST BE COMPLETED AND THEN SIGNED BY THE APPROPRIATE COLLEGE OR UNIVERSITY OFFICIAL

This verifies that the individual referenced above has applied for admission or is enrolled at (Name of College/University)
for the academic year 20
– 20
.
He/She will be enrolled in either a full-time or part-time (circle one) undergraduate/graduate curriculum which fulfills
the requirement for admission into his/her chosen health program identified above. The individual will be enrolled/or is
.
anticipated to be enrolled in the following courses commencing Fall 20
***ATTACH CURRICULUM FOR MAJOR FROM FIRST YEAR TO COMPLETION***
Semester I / Trimester I / Quarter I (Required)
COURSE NUMBER
CREDIT HOURS

TOTAL S / T / Q HOURS:
COURSE TITLE

Semester II / Trimester II / Quarter II (Required)
COURSE NUMBER
CREDIT HOURS

TOTAL S / T / Q HOURS:
COURSE TITLE

Continues on back
NAME (Print)

POSITION TITLE (Required)

SIGNATURE

DATE

IHS-856-6

PHONE NUMBER

EF

Trimester III / Quarter III (Required, if applicable)
COURSE NUMBER
CREDIT HOURS

Quarter IV (Required, if applicable)
COURSE NUMBER
CREDIT HOURS

TOTAL T / Q HOURS:
COURSE TITLE

TOTAL Q HOURS:
COURSE TITLE

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 42 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.