IHS-856-11 Deferment Approval Request

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

DEFERMENT APPROVAL REQEUST
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
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 8 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.