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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 10/31/2023
See Estimated Average Burden Time
per Response on page 2.
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
DEFERMENT APPROVAL REQUEST
RECIPIENT’S NAME
DEGREE PROGRAM
ADDRESS
PHONE: CELL
IHS AREA OFFICE
HOME
EMAIL ADDRESS
This document notifies the IHS Scholarship Program of your selected residency/training program,
if approved this will delay the service commitment incurred under 25 U.S.C. 1613a and pursuant to your Contract with IHS.
POST-GRADUATE CLINICAL TRAINING PROGRAM:
PROGRAM DIRECTOR (Name):
PROGRAM ADDRESS:
CITY
STATE
PHONE
LENGTH OF PROGRAM:
ZIP CODE
EMAIL ADDRESS
START DATE
END DATE
DATE AVAILABLE TO BEGIN SERVICE COMMITMENT:
EMERGENCY CONTACT INFORMATION
NAME
ADDRESS
PHONE: CELL
CITY
STATE
RECIPIENT’S SIGNATURE
HOME
ZIP CODE
DATE
Return to:
Indian Health Service
Scholarship Program
5600 Fishers Lane
Mail Stop: OHR (11E53A)
Rockville, MD 20857
Reviewed (IHS use only):
Approved (IHS use only):
Analyst, Branch Chief or Designee
IHS-856-14
EF
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 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, Scholarship Program, 5600 Fishers Lane,
Mail Stop: OHR (11E53A), Rockville, MD 20857.
File Type | application/pdf |
File Title | PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM NOTIFICATION OF DEFERMENT PROGRAM |
Subject | IHS, Indian Health Service, PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM NOTIFICATION OF DEFERMENT PROGRAM |
Author | IHS PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM NOTIFICATION |
File Modified | 2023-10-20 |
File Created | 2017-03-30 |