Form IHS-856-16 Annual Status Report

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

ANNUAL STATUS REPORT
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

ASSIGNMENT:

Indian Health Service

Urban Indian Health Program

Private Practice

Tribal Facility

NAME OF FACILITY

ADDRESS

MY CURRENT POSITION TITLE:
HEALTH PROFESSION Career CategorY (when funded by the IHS Scholarship Program):
Entry-on-Duty DATE:
Years remaining of service obligation:
(ATTACH TO THIS REPORT A COPY OF YOUR PERSONNEL ORDERS OR SF-50 AND A COPY OF YOUR CURRENT POSITION DESCRIPTION.)
NON-IHS EMPLOYEES MUST ATTACH A SUMMARY WHICH IDENTIFIES THE PURPOSE, MISSION OR NATURE OF THE EMPLOYING
ORGANIZATION AND THE POPULATION SERVED BY THE ORGANIZATION.

COMMENTS:

EMPLOYEE’S SIGNATURE

DATE

SUPERVISOR’S TITLE (Print)

PHONE

SUPERVISOR’S SIGNATURE

DATE

Return to:
IHS Scholarship Program
Attn: Program Analyst
801 Thompson Ave., Suite 120
Rockville, MD 20852



Reviewed (IHS use only): 
Analyst, Branch Chief or Designee
IHS-856-16

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 15 minutes per response including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to Indian Health Service, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.