IHS Scholarship Program Application

Application for Participation in the IHS Scholarship Program

SCHOLARSHIP PROGRAM WEB SITE APPLICATION

IHS Scholarship Program Application

OMB: 0917-0006

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0917-0006 can be found here:

2023-10-31 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

SCHOLARSHIPONLINE APPLICATIONI Indian Health Service (IHS)

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U.S. Department of Health and Human Services

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directives, and other federal guidance for accessing this Government system, which includes (1)
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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find A-Mail Stop

https://wwwqa.ihs.gov/scholarship/online-applicatiorV

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IHS Scholarship

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Scholarship Online Application

IHS Scholarship Program
Main

Student Portal
*

lndicates required field

Welcome to the IHS Scholarship Program Online Application. The IHS Scholarship Program is now

accepting applications for scholarship awards for the 2020-2021 academic year. Follow the instructions
below if you have questions about how to create account or log in to your existing account.
*_EmailAddress

Password

t:lLooin ll

Forqot Password?
Retrieve EmailAddress I Create Account

Application deadlines

Extension Applicants: February 28,2020 by 7 pm EDT
NewApplicants: Due February 28,2020 by 7 pm EDT

lnstructions:
FIRST TIME USERS: Click "Greate Account" if you are a first-time applicant who has never used the

online system to submit an application.

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RETURNING USERS: Enter the email address and password associated with your account. lf you no
Ionger have access to your email address, please contact the Scholarship Program at 301-443-61 97 for
assistance.

APPLICATION PORTAL: Once you have created an account or logged in using your existing email
address and password, you will be directed to one of the following applications:

.
.

New application: For applicants who are not IHS scholarship recipients.
Extension application: Forcurrent scholarship recipients applying to extend yourscholarship or
update your scholarship status.

Contact the IHS Scholarship Program office immediately at (301 ) 443-6197 if you believe you have been
directed to the wrong application portal or are experiencing trouble creating/accessing your account.

https ://wwwqa.ihs. gov/scholarship/online-application/index.cfm

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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - [ind a Maii Sl*r:

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IHS Scholarshio Proqram

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Scholarship Online Application

IHS Scholarship Prog ram
Profile

Degree Program
College/ University
Educational Background
Course Curriculum Verification
Faculty/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of nformation
I

Form Approved,OMB Approval No. 0917-0006, Expiration Da1e.0312012020

Profile

Save and Logout

Required Field
Complete the required profile information.

First Name

Middle Name

Last Name

Social Security Number

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Whv do we collect vour Social Securitv number?

Drtu of Birth

f-_--r
*

Gender

Female v
*

Home/Primary

Work/Mobile

Mailing Address
*

Address Line I

Address Line 2

city

* st"t"
Please

select

Alternate Mailing Address
Address Line

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Address Line 2
I
I

State

Please select

Emergency Contact - ldentify a person or relative through whom you can always
be located.
*

First Name

Last Name

Current Address

* city

* st"t"
Please

select

zip

Phon"

https://wwwqa.ihs.gov/scholarship/online_application/apply.cfm?APP _ID:4787

0&WAMPR...

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Area Scholarship Coord inator
Select the Area office that supports your Tribe.

IHS Area Office

Please

select

IHS Area Offices Locations

Save and Continue
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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stop

https://wwwqa.ihs.gov/scholarship/online_application/apply.cfm?APP _ID:47870&WAMPR... 1211312019

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IHS Home

IHS Scholarship Proqram

Scholarship Online Application

IHS Scholarship Program
Profile

Degree Program
College/ University
Educational Background
Course Curriculum Verification

Facul$/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of lnformation
Form Approved,OMB Approval No. 0917-0006, Expiration Dale:0312012020

Save and Logout

Degree Program
Required Field

ldentify your level of school for the 2O2O-2O21academic

year:

help?

Colleqe/Universitv

Q Sophomore
Q Junior
Q Senior
Graduate/Health Professions School

Q First Year
Q Second Year
Q

Third Year

Q Fourth Year

https ://wwwqa. ihs. gov/scholarship/online-application/apply. cfm

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Q Pursuing
Q Other

(IHS)

Page 2

Second Degree

ldentify the degree program you will be enrolled in for the 2020-2021 academic year. View Comparison
chart [PDF - 118K8]

* D"gr"" Program
Please Select

What is your anticipated graduation date for your selected degree program? help?

Graduation Date
Month

Year v

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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stop

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U.S. Department of Health and Human Services

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Scholarship Online Application

IHS Scholarship Program
Profile

uegree Program
College/ University
Educational Background
Course Curriculum Verification
Facu lty/ Employer
-Evaluation

Delinquent Federal Debt
Narrative Statements
Confirmation of nformation
I

Form Approved,OMB Approval No. 0917-0006, Expiration Oale:0312012020

College/U niversity I nformation

Save and Logout

Required Field
You are required to provide information on your current college/university or the college/university you plan on
attending next academic year. lf you are applying or have been accepted for enrollment at more than one
school, you must enter the information for your preferred school. ln the provided text box, include the names of
any additional colleges where you have submitted an application or have been accepted for enrollment. You
must be applying to study in the same degree program at each of these schools.
ldentify your enrollment status at your current or preferred college/university for lhe 2A20-202'l school year:*

Q Currently Enrolled
Q Accepted for Enrollment
Q

Applied for Enrollment

ldentify the college/university in which you are currently enrolled, have been accepted for enrollment or to which
you have applied for enrollment:*

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College/University: Name

Other (if not listed

above):

i Please Select
1.,**__*

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Other Name

List the names of the other schools where you have applied or where you have been accepted for enrollment:

College/U niversity Location
*

city

* st"t"
Vi

ldentify your residency status at the college/university you selected above:*

Q
Q
Q

ResidenUln-State

Non-ResidenUOut-of-State
School charges the same tuition and fees regardless of resident status

lndicate your anticipated enrollment status for the 2020-2021 academic year:*

Q FullTime
Q Part Time
lndicate the anticipated number of credit hours you will be enrolled in for the 2020-2021fall semester.

Credit Hours

f"*,;l@

Save and Continue
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IHS Headquarters, lndian Health Service,5600 Fishers Lane, Rockville, MD 20857 - Frnd a Mail Stop

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U.S. Deoartment of Health and Human Services

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IHS Home

Indian Health Service
The Federal Health Program for American lndians and Alaska Natives

IHS Scholarship Prooram

Scholarship Online Application

IHS Scholarship Program
Profile

Degree Program
College/ University
Educational Background
Course Curriculum Verification
Faculty/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of lnformation
Form Approved,OM B Approval No. 09 1 7-0006, Expiration

ale:03 12012020

Higher Education Background

Save and Logout

Required Field
you are required to provide the following information for ALL colleges/universities that you have attended. Click
"Add College/University" after each entry. Once you have entered all colleges/universities, click "Save &
Continue" to move on to Course Curriculum Verification.
An official transcript is required for each college/university you have attended; failure to provide this information
will result in your application being deemed incomplete.

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* st"t"
Please

select

Dates Attended
From

Month:lTv"rr,ll
To
Month:

L:
*

Credits Completed

Cumulative GPA

i:_:

* D"gr"" Earned

Monthl/ear Degree Was Obtained

Month:[-Tv"rr,f--!
Add CollegelU niversity

til;l@

Save and Continue
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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stop

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U.S. Deoartment of Health and Human Services

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IHS Scholarship Proqram

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Scholarship Online Application

IHS Scholarship Program
Profile

Degree Program
College/ University
Educational Backgrou nd
Course Curriculum Verification
Faculty/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of I nformation
Form Approved,OMB Approval No. 09 1 7-0006, Expiration

ale:0312012020

Course Curriculum Verification

Save and Logout

Required Field
Academic Year:
2020-2021

College/University:
Enrollment Status:

lnstructions to complete this form:

.
.
.

Enter the number of academic terms in which you have enrolled or plan to enroll in during lhe 2020'2021

academic year.
List the courses for which you have registered or plan to register during each academic term (semester,
quarter, trimester, etc.).
Courses are for the 2020-2021 academic year ONLY. Do not enter your projected coursework for every
academic term until you graduate.

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.
.

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lnclude the course numbers, credit hours, course titles and number of credit hours for each term. lfyour
school does not assign credit hours, please indicate 0 (zero) in the credit hours column.
You can add a course under each academic term by clicking the "Add" button.
You can edit courses by clicking the "Update" or "Delete" buttons.

This form must be completed, per instructions, for your application to be considered for an award. You cannot
enter "see my Curriculum for Major" or use any other documentation of courses in place of completing this form.
lf you have not yet registered or courses have not been assigned, you must still complete this form with a list of

courses you plan to take, based on your degree program's Curriculum for Major.
You are required to update any changes in your projected coursework prior to the application deadline. Contact
the IHS Scholarship Proqram if you have submitted your application and need your application to be unlocked.

Number of Academic Terms (including summer school, if applicable):

L_ltrG;l
Save and Continue
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IHS Headquarlers, lndian Health Service, 5600 Fishers Lane, Rockville, lrD 20857 - Find a Mail Stoo

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IHS Scholarship Proqram

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Scholarship Online Application

IHS Scholarship Program
Profile

lJegree Program
College/ University
Educational Background
Course Curriculum Verification
Faculty/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of lnformation
Form Approved,OMB Approval No. 0917-0006, Expiration Oale:0312012020

Facu lty/Em ployer Eval uation

Save and Logout

Required Field
Provide contact information for two faculty members, employers or other references who can adequately

evaluate you on:

.
.
.

Educational/work achievement.
Relationships with people.
Potential to work as a health professional.

The IHS Scholarship Program recommends that you contact your chosen evaluators to request permission to
use them as references.
Evaluators cannot be related to you by blood or marriage.

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Your evaluators will receive a system-generated email requesting their participation immediately
upon submitting their contact information. You should follow up with your evaluator(s) to
confirm that they received the email. lf it is not in their inbox, ask that they check their Junk or
Spam folder.
It is your responsibility to ensure that the online forms are submitted by February 28,2020 at7
pm EDT. Evaluation form links will be deactivated once the deadline has passed.

Evaluator #1
*

First Name:

Last Name:

EmailAddress:

Phone Number:

Submit Evaluator

Evaluator #2
x

First Name:

Last Name:

EmailAddress:

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Phon" Number:

Submit Evaluator

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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stqp

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Scholarship Online Application

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Profile

Save and Logout

Delinquent Federal Debt
Required Field

* Ar" you delinquent

on the repayment of any federal debts?

QYes CNo
Examples of federal debt include delinquent taxes, audit disallowances, guaranteed or direct student loans,
FHA loans, and other miscellaneous administrative debts. Delinquency is defined as being more than 31 days
pastdueon a scheduled paymentfordirectand guaranteed loans. IHS does notconsiderdeferred loansto be
delinquent.

Save and Continue
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QHS)

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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stop

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U.S. Deoartment of Health and Human Services

Indian Health Service

{w
IHS Home

The Federal Health Program for American lndians and Alaska Natives

IHS Scholarship Proqram

Scholarship Online Application

IHS Scholarship Program
Profile

Degree Program
College/ University
Educational Backgrou nd
Course Curriculum Verification
Faculty/ Employer Evaluation
Delinquent Federal Debt
Narrative Statements
Confirmation of lnformation
Form Approved,OMB Approval No. 0917-0006, Expiration Dale:0312012020

Narrative Statements

Save and Logout

Required Field
prepare essays addressing the three questions below. The text boxes on this screen provide unlimited space. lt
may be helpful to prepare your statements in advance and then copy and paste them into the appropriate fields.

HELPFUL HINTS
Below are helpful hints to guide you through completion of your statements. These statements make up
30 percent of your score, so it is important to organize your thoughts, be descriptive, and use correct
grammar.

1. The IHS Scholarship Program does not provide scholarship awards due to financial hardships.
\Men providing an explanation as to why you are requesting a scholarship, do not indicate that
you are in need of financial assistance.

2. You should include in your statements

how you are going to give back to the community. A
prerequisite of all IHS Scholarship Program applicants is that you intend to serve lndian people in
your chosen health profession.

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3. lnclude any information on participation or achievements in health-related fields.
4. Provide insight into what led you to pursue a career as a health professional.
5. Provide examples of your involvement in tribal activities.
6. We recommend a minimum of 200 words per essay for each question to accurately

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address each

section.

Explain why you are requesting this scholarship:

* Strt"

your career goals:

Explain how these goals will help to meet the health needs of American lndians and Alaska Natives:

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IHS Headquarters, lndian Health Service, 5600 Fishers Lane, Rockville, MD 20857 - Find a Mail Stop

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Scholarship Online Application

IHS Scholarship Program
Profile

Confirmation of lnformation - Page

Save and Logout

You must complete all areas appearing in red below (if applicable) prior to confirming this screen.

Eligibility
United States Citizen or National:
Yes

Native Origin:
American lndian

Tribal Membership Status:
Member of a federally-recognized tribe or Alaskan village'

Tribe/Village:
MUSCOGEE (CREEK) NATION, OK

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File Type	application/pdf
File Modified	0000-00-00
File Created	2019-12-18