Application for Admission to Haskell Indian Nations University

OMB CONTROL #1076-0114

Expires: 12/31/2008

Paperwork Reduction Act and Public Burden Statement:

Authority: Paperwork Reduction Act of 1995, Public Law 96-511, as amended.

This information is collected of Native American and Alaska Native individuals to determine eligibility for post-secondary education services, assist in the enrollment process, identification of students, identification of needed health and counseling services, safety issues related to dormitory situations and for record keeping purposes. The completed admissions forms are electronically entered into Haskell Indian Nations University Admissions and Records system to identify and maintain current information on students, the collected data is used in responding to the Bureau of Indian Education’s budget information requests from the Department of the Interior, Office of Management and Budget, and Congress, the collected information is used to supply needed information to counselors for student services and is used by health professionals to aid in the provision of health services. The estimated burden of completing this form will take an average of 30 minutes to gather all related information and to complete the form. If you wish to make comments on the form, please send them to the Information Collection Clearance Officer, Bureau of Indian Affairs, 625 Herndon Parkway, Herndon, VA 20170. Note: comments, names and addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB clearance number.

Privacy Act Statement:

Authority: Privacy Act of 1974, Public Law 93-579, as amended.

This information collection document contains information that is covered under the Privacy Act Public Law and is for students completing Federal records and forms that solicit personal information. The Bureau of Indian Education will not disclose any record containing such information without the written consent of the respondent unless the requestor uses the information to perform assigned duties. The primary purpose and routine uses of this information is to determine eligibility for postsecondary educational services of the Southwestern Indian Polytechnic Institute, for identification purposes, to render appropriate services for students and for record keeping purposes. Examples of others who may request the information in summary are Members of Congress, or the Office of Management and Budget for the purpose of the budget. Collection of your Social Security Number is for identification purposes and is voluntary. Your voluntary responses are treated in a highly confidential manner.

EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. If you choose not to provide information it may affect your eligibility for educational services.