IHS-856-9 Notification of Academic Problem

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 10/31/2023

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

NOTIFICATION OF ACADEMIC PROBLEM
RECIPIENT’S NAME

See Estimated Average Burden
Time per Response on page 2.

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

SCHOLARSHIP:

Preparatory

Pre-Graduate

Fall

Winter

Spring

Semester

Quarter

Trimester

Full-time

Part-time

ACADEMIC TERM:

ENROLLMENT STATUS:

Health Professions
Summer

INDICATE WHICH OF THE FOLLOWING APPLIES TO YOU:
I am having problems with my courses.

I am considering withdrawing from school.

My advisor has recommended that I
drop one or more of my courses.

I have been dismissed from school.

Current Enrolled Credit Hours

Proposed Credit Hours

Description of problem:

List by course number, title and hours the courses you are having problems in:
COURSE NUMBER

TITLE

HRS.

COURSE NUMBER

TITLE

HRS.

Explain your proposed action (for example, seek tutorial assistance, withdraw from course(s), repeat course(s), etc.):

Required signature on back of this form
IHS-856-9

EF

RECIPIENT’S SIGNATURE

DATE

ADVISOR/COUNSELOR NAME (Print)

POSITION TITLE

ADVISOR/COUNSELOR SIGNATURE

DATE

PHONE: CELL

OFFICE

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 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.