IHS-856-15 Placement Update

DEPARTMENT 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

PLACEMENT UPDATE
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

HAVE YOU BEEN PLACED AT AN APPROVED IHS, TRIBAL OR URBAN INDIAN PROGRAM?

Yes

No

If yes, provide the:
NAME OF FACILITY:
POSITION TITLE:
START DATE:
If no, please attach documentation of your efforts to secure placement (e.g., proof of application/rejection). You must submit another
Placement Update form in 30 days providing further information on your efforts to begin your service commitment.
If you have reached the 90 day limit and have not accepted placement at one of your preferred sites, or cannot find employment,
the Director of IHS may place you at an Indian health facility based on the needs of the IHS.

GRADUATION DATE:
COLLEGE/UNIVERSITY:
DEGREE OBTAINED:

Required signature on back of this form
IHS-856-15

EF

LIST POSITION(S) APPLIED FOR:
JOB 1

Vacancy Announcement #:
Job Title:
Location:
Date Applied:

Application Status:

JOB 2

Vacancy Announcement #:
Job Title:
Location:
Date Applied:

Application Status:

JOB 3

Vacancy Announcement #:
Job Title:
Location:
Date Applied:

Application Status:

JOB 4

Vacancy Announcement #:
Job Title:
Location:
Date Applied:

Application Status:

Use additional sheets as needed.

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

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0917-0006. This information collection is for the purposes of the Indian Health Service
Scholarship Program to provide Preparatory, Pre-graduate, and Health Professions Scholarships to students
pursuing health professions education and training and the information collected will be used to identify
qualified American Indian/Alaska Native students. The time required to complete this information collection is
estimated to average less than 11 minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, to review and complete the information collection. This
information collection is required to obtain or retain a benefit (25 U.S.C. § 1613 and 25 U.S.C. § 1613a) and is
subject to Privacy Act safeguards, 5 U.S.C. § 552a(e)(4) and the nature and extent of confidentiality is set
forth in the Privacy Act and SORN # 09-17-0002, described at 74 FR 50222 (September 30, 2009). If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: Indian Health Service, IHS Information Collections Clearance Officer, 5600 Fishers Lane, Mail stop: 09E70,
Rockville, MD 20857.