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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: 9/30/2020
See Estimated Average Burden Time
per Response on page 2.
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
NOTICE OF IMPENDING GRADUATION
RECIPIENT’S NAME
DEGREE PROGRAM
ADDRESS
PHONE: CELL
IHS AREA OFFICE
HOME
EMAIL ADDRESS
GRADUATION DATE (month/day/year):
COLLEGE/UNIVERSITY:
TYPE OF DEGREE:
Have you begun your job search?
Yes
No
Have you contacted an IHS recruiter, your Program Analyst or your Discipline Chief for assistance?
Have you applied for placement at an IHS, Tribal or Urban Indian Program facility?
Do you need assistance seeking placement to fulfill your service commitment?
Yes
Yes
Yes
No
No
No
COMMENTS:
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-856-13
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, 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 NOTICE OF IMPENDING GRADUATION |
Subject | IHS, Indian Health Service PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM NOTICE OF IMPENDING GRADUATION |
Author | IHS PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM NOTICE OF IM |
File Modified | 2020-09-01 |
File Created | 2017-03-30 |