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pdfDEPARTMENT 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
NOTICE OF IMPENDING GRADUATION
RECIPIENT’S NAME
SOCIAL SECURITY NUMBER
ADDRESS
CAREER CATEGORY
PHONE: CELL
IHS AREA OFFICE
Home
EMAIL ADDRESS
Graduation Date (month/day/year):
College/University:
Type of Degree:
Have you reviewed the IHS vacancies database?
Yes
No
Have you applied for placement at an IHS, Tribal or Urban facility?
Have you contacted your IHS Discipline Chief?
Yes
Yes
No
No
Do you need assistance seeking placement to fulfill your service obligation?
Yes
No
COMMENTS:
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-856-13
EF
ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 10 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.
File Type | application/pdf |
File Modified | 2009-10-08 |
File Created | 2009-07-14 |