Application for Participation in the IHS Scholarship Program

Forms and Documents

Document Name	Status
Form IHS-856-6 Course Curriculum Verification Form	Unchanged
Form IHS-856-3 Faculty/Employer Evaluation Form	Unchanged
Form IHS 818 Health Professions Contract Form	Modified
Form IHS-817 Scholarship Program Agreement Form	Modified
Form IHS-856-24 Faculty/Advisor Evaluation Form	Unchanged
Form IHS-856-23 Request for Credit Validation Form	Unchanged
Form IHS-856-22 Change of Name or Address Form	Unchanged
Form IHS-856-21 Summer School Request Form	Unchanged
Form IHS-856-19 Lost Stipend Payment Form	Unchanged
Form IHS-856-18 Request for Extern Travel Reimbursement Form	Unchanged
Form IHS-856-17 Extern Site Preference Request Form	Unchanged
Form IHS-856-16 Annual Status Report Form	Unchanged
Form IHS-856-15 Placement Update Form	Unchanged
Form IHS-856-14 Notification of Deferment Program Form	Unchanged
Form IHS-856-13 Notice of Impending Graduation Form	Unchanged
Form IHS-856-12 Preferred Placement Form	Unchanged
Form HS-856-11 Request for Approval of Deferment Form	Unchanged
Form IHS-856-10 Change of Status Form	Unchanged
Form IHS-856-9 Notification of Academic Problem Form	Unchanged
Form ihs-856-8 Recipient's Initial Program Progress Report Form	Unchanged
Form IHS-856-7 Verification of Acceptance or Decline of Award Form	Unchanged
Form IHS-856-5 Delinquent Federal Debt Form	Unchanged
Supporting_Statement_for_OMB_No__0917-0006 -Final 3.24.17.docx Supporting Statement A	2017-03-24

IC Document Collections

IC ID	Document Title	Status
193119	Course Curriculum Verification Form	Unchanged
193118	Faculty/Employer Evaluation Form	Unchanged
193117	Health Professions Contract Form	Modified
193116	Scholarship Program Agreement Form	Modified
183630	Faculty/Advisor Evaluation Form	Unchanged
183629	Request for Credit Validation Form	Unchanged
183628	Change of Name or Address Form	Unchanged
183627	Summer School Request Form	Unchanged
183625	Lost Stipend Payment Form	Unchanged
183624	Request for Extern Travel Reimbursement Form	Unchanged
183623	Extern Site Preference Request Form	Unchanged
183622	Annual Status Report Form	Unchanged
183621	Placement Update Form	Unchanged
183620	Notification of Deferment Program Form	Unchanged
183619	Notice of Impending Graduation Form	Unchanged
183618	Preferred Placement Form	Unchanged
183617	Request for Approval of Deferment Form	Unchanged
183616	Change of Status Form	Unchanged
183615	Notification of Academic Problem Form	Unchanged
183614	Recipient's Initial Program Progress Report Form	Unchanged
183613	Verification of Acceptance or Decline of Award Form	Unchanged
183612	Delinquent Federal Debt Form	Unchanged

ICR Details

OMB Control No: 0917-0006	ICR Reference No: 201609-0917-001
Status: Historical Active	Previous ICR Reference No: 201308-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No: 19731
Title: Application for Participation in the IHS Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2017
	Date Received in OIRA: 09/22/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	12,580	0	12,580
Time Burden (Hours)	4,340	0	4,340
Cost Burden (Dollars)	0	0	0

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Abstract: Program forms collect information used to solicit, process and award scholarships, monitor academic performance and place awardees in payback sites. The data is needed to plan, manage, direct, operate and evaluate the IHSA Scholarship program.

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Authorizing Statute(s): PL: Pub.L. 94 - 437 522 Name of Law: Indian Health Care Improvement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 44030	07/06/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 60368	09/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 22

IC Title	Form No.	Form Name
Delinquent Federal Debt	IHS-856-5	Delinquent Federal Debt
Verification of Acceptance or Decline of Award	IHS-856-7	Verification of Acceptance or Decline of Award
Recipient's Initial Program Progress Report	ihs-856-8	Recipient's Initial Program Progress Report
Notification of Academic Problem	IHS-856-9	Notification of Academic Problem
Change of Status	IHS-856-10	Change of Status
Request for Approval of Deferment	HS-856-11	Request for Approval of Deferment
Preferred Placement	IHS-856-12	Preferred Placement
Notice of Impending Graduation	IHS-856-13	Notice of Impending Graduation
Notification of Deferment Program	IHS-856-14	Notification of Deferment Program
Placement Update	IHS-856-15	Placement Update
Annual Status Report	IHS-856-16	Annual Status Report
Extern Site Preference Request	IHS-856-17	Extern Site Preference Request
Request for Extern Travel Reimbursement	IHS-856-18	Request for Extern Travel Reimbursement
Lost Stipend Payment	IHS-856-19	Lost Stipend Payment
Summer School Request	IHS-856-21	Summer School Request
Change of Name or Address	IHS-856-22	Change of Name or Address
Request for Credit Validation	IHS-856-23	Request for Credit Validation
Faculty/Advisor Evaluation	IHS-856-24	Faculty-Advisor Evaluation
Scholarship Program Agreement	IHS-817	Scholarship Program Agreement
Health Professions Contract	IHS 818	Contract
Faculty/Employer Evaluation	IHS-856-3	Faculty/Employer Evaluation
Course Curriculum Verification	IHS-856-6	Course Curriculum Verification

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	12,580	12,580	0	0	0	0
Annual Time Burden (Hours)	4,340	4,340	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $107,713

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/22/2016

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