Form IHS-856-13 Notice of Impending Graduation

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

NOTICE OF IMPENDING GRADUATION
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

CAREER CATEGORY

PHONE: CELL

IHS AREA OFFICE

Home

EMAIL ADDRESS

Graduation Date (month/day/year):
College/University:
Type of Degree:
Have you reviewed the IHS vacancies database?

Yes

No

Have you applied for placement at an IHS, Tribal or Urban facility?
Have you contacted your IHS Discipline Chief?

Yes

Yes

No

No

Do you need assistance seeking placement to fulfill your service obligation?

Yes

No

COMMENTS:

RECIPIENT’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-856-13

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 10 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.