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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
PREFERRED PLACEMENT
RECIPIENT’S NAME
DEGREE PROGRAM
ADDRESS
PHONE: CELL
IHS AREA OFFICE
HOME
EMAIL ADDRESS
BACKGROUND
GRADUATION DATE:
DEGREE OBTAINED:
COLLEGE/UNIVERSITY:
DESCRIBE YOUR PREFERRED WORK ASSIGNMENT:
MY SERVICE COMMITMENT IS FOR A PERIOD OF
YEARS.
INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR PLACEMENT:
Albuquerque
California
Oklahoma City
Anchorage
Great Plains
Phoenix
Bemidji
Nashville
Portland
Billings
Navajo
Tucson
INDICATE YOUR PREFERRED IHS, TRIBAL OR URBAN INDIAN PROGRAM FACILITY TO COMPLETE YOUR SERVICE COMMITMENT:
(1)
(4)
(2)
(5)
(3)
(6)
I understand that I must submit a position description at my chosen Indian health facility for review and approval by the IHS Scholarship Program before
beginning to fulfill my service commitment.
RECIPIENT’S SIGNATURE
DATE
Return to:
Indian Health Service
Scholarship Program
5600 Fishers Lane
Mail Stop: OHR (11E53A)
Rockville, MD 20857
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 30 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 PREFERRED PLACEMENT |
Subject | IHS, Indian Health Service, PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM PREFERRED PLACEMENT |
Author | IHS PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM PREFERRED PL |
File Modified | 2021-02-23 |
File Created | 2017-03-30 |