Application for Participation in the IHS Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form IHS-856-13 Notice of Impending Graduation	Form and Instruction	New	Available
Form IHS-856-13 Notification of Impending Graduation	Form and Instruction	New	Repair queued
Form IHS 818 Contract	Form	Modified	Available
Form IHS 818 Health Professions Contract	Form	Modified	Repair queued
Form IHS-817 Scholarship Program Agreement	Form	Modified	Available
Form IHS-817 Scholarship Program Agreement	Form	Modified	Repair queued
Form IHS-856-23 Request for Credit Validation	Form	Removed	Repair queued
Form IHS-856-23 Request for Credit Validation	Form	Removed	Repair queued
Form IHS-856-22 Change of Name or Address	Form and Instruction	Modified	Available
Form IHS-856-22 Change of Name or Address	Form	Modified	Repair queued
Form IHS-856-21 Summer School Request	Form and Instruction	Modified	Available
Form IHS-856-21 Summer School Request	Form	Modified	Repair queued
Form IHS-856-19 Lost Stipend Payment	Form	Removed	Available
Form IHS-856-19 Lost Stipend Payment	Form	Removed	Repair queued
Form IHS-856-16 Annual Status Report	Form and Instruction	Modified	Available
Form IHS-856-16 Annual Status Report	Form	Modified	Repair queued
Form IHS-856-15 Placement Update	Form and Instruction	Modified	Available
Form IHS-856-15 Placement Update	Form	Modified	Repair queued
Form IHS-856-14 Notification of Deferment Intent	Form and Instruction	Modified	Available
Form IHS-856-14 Notification of Deferment Program	Form	Modified	Repair queued
Form IHS-856-13 Notice of Impending Graduation	Form	Removed	Available
Form IHS-856-13 Notice of Impending Graduation	Form	Removed	Repair queued
Form IHS-856-12 Preferred Placement	Form and Instruction	Modified	Available
Form IHS-856-12 Preferred Placement	Form	Modified	Repair queued
Form IHS-856-11 Deferment Approval Request	Form and Instruction	Modified	Available
Form HS-856-11 Request for Approval of Deferment	Form	Modified	Repair queued
Form IHS-856-10 Change of Status	Form and Instruction	Modified	Available
Form IHS-856-10 Change of Status	Form	Modified	Repair queued
Form IHS-856-9 Notification of Academic Problem	Form and Instruction	Modified	Available
Form IHS-856-9 Notification of Academic Problem	Form	Modified	Repair queued
Form IHS-856-8 Progress Report	Form and Instruction	Modified	Available
Form IHS-856-8 Recipient's Initial Program Progress Report	Form	Modified	Repair queued
Form IHS-856-7 Verification of Acceptance or Decline of Award	Form and Instruction	Modified	Available
Form IHS-856-7 Verification of Acceptance or Decline of Award	Form	Modified	Repair queued
Supporting Statement for IHS Scholarship Program FINAL 10.30.23.docx	Supporting Statement A	Uploaded 2023-10-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263141	Notification of Impending Graduation	Form and Instruction	New	Notice of Impending Graduation
263141	Notification of Impending Graduation	Form and Instruction	New
240987	IHS Scholarship Program Application	Other-Web Site Apps	Unchanged
193117	Health Professions Contract	Form	Modified	Contract
193117	Health Professions Contract	Form	Modified
193116	Scholarship Program Agreement	Form	Modified	Scholarship Program Agreement
193116	Scholarship Program Agreement	Form	Modified
183629	Request for Credit Validation	Form	Removed	Request for Credit Validation
183629	Request for Credit Validation	Form	Removed
183628	Change of Name or Address	Form and Instruction	Modified	Change of Name or Address
183628	Change of Name or Address	Form	Modified
183627	Summer School Request	Form and Instruction	Modified	Summer School Request
183627	Summer School Request	Form	Modified
183625	Lost Stipend Payment	Form	Removed	Lost Stipend Payment
183625	Lost Stipend Payment	Form	Removed
183622	Annual Status Report	Form and Instruction	Modified	Annual Status Report
183622	Annual Status Report	Form	Modified
183621	Placement Update	Form and Instruction	Modified	Placement Update
183621	Placement Update	Form	Modified
183620	Notification of Deferment Program	Form and Instruction	Modified	Notification of Deferment Intent
183620	Notification of Deferment Program	Form	Modified
183619	Notice of Impending Graduation	Form	Removed	Notice of Impending Graduation
183619	Notice of Impending Graduation	Form	Removed
183618	Preferred Placement	Form and Instruction	Modified	Preferred Placement
183618	Preferred Placement	Form	Modified
183617	Request for Approval of Deferment	Form and Instruction	Modified	Deferment Approval Request
183617	Request for Approval of Deferment	Form	Modified
183616	Change of Status	Form and Instruction	Modified	Change of Status
183616	Change of Status	Form	Modified
183615	Notification of Academic Problem	Form and Instruction	Modified	Notification of Academic Problem
183615	Notification of Academic Problem	Form	Modified
183614	Progress Report - Recipient's Initial Report	Form and Instruction	Modified	Progress Report
183614	Recipient's Initial Program Progress Report	Form	Modified
183613	Verification of Acceptance or Decline of Award	Form and Instruction	Modified	Verification of Acceptance or Decline of Award
183613	Verification of Acceptance or Decline of Award	Form	Modified

ICR Details

OMB Control No: 0917-0006	ICR Reference No: 202310-0917-001
Status: Active	Previous ICR Reference No: 202003-0917-001
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: 01/30/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/31/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved	01/31/2024
Responses	3,235	0	3,275
Time Burden (Hours)	1,282	0	1,286
Cost Burden (Dollars)	0	0	0

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Abstract: The IHS Scholarship Program offers qualified American Indian and Alaska Native health profession students a unique opportunity to establish an educational foundation as they prepare to pursue a career in Indian health. Each scholarship (Preparatory, Pre-Graduate and health professions) is defined by applicant and degree program eligibility and provides generous financial aid packages (information available at www.ihs.gov/scholarship). The ultimate goal of the program is to develop health care providers and the next leaders of Indian health communities. Since IHS began providing scholarship support to American Indian and Alaska Native students to pursue health profession careers in 1978, the program has grown to support, educate and place health care professionals within medically underserved Indian health programs throughout the continental United States and Alaska. Today, nearly 7,000 American Indian and Alaska Native students have received scholarship awards and many have committed to serving their health profession careers at IHS; some have even returned to serve their own Tribal communities.

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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:
	88 FR 59929	08/30/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 74499	10/31/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Annual Status Report	IHS-856-16	Annual Status Report
Change of Name or Address	IHS-856-22	Change of Name or Address
Change of Status	IHS-856-10	Change of Status
Health Professions Contract	IHS 818	Contract
IHS Scholarship Program Application
Lost Stipend Payment	IHS-856-19	Lost Stipend Payment
Notice of Impending Graduation	IHS-856-13	Notice of Impending Graduation
Notification of Academic Problem	IHS-856-9	Notification of Academic Problem
Notification of Deferment Program	IHS-856-14	Notification of Deferment Intent
Notification of Impending Graduation	IHS-856-13	Notice of Impending Graduation
Placement Update	IHS-856-15	Placement Update
Preferred Placement	IHS-856-12	Preferred Placement
Progress Report - Recipient's Initial Report	IHS-856-8	Progress Report
Request for Approval of Deferment	IHS-856-11	Deferment Approval Request
Request for Credit Validation	IHS-856-23	Request for Credit Validation
Scholarship Program Agreement	IHS-817	Scholarship Program Agreement
Summer School Request	IHS-856-21	Summer School Request
Verification of Acceptance or Decline of Award	IHS-856-7	Verification of Acceptance or Decline of Award

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ICR Summary of Burden

table that charts list 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	3,235	3,275	0	170	-210	0
Annual Time Burden (Hours)	1,282	1,286	0	28	-32	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The program made adjustments in two forms, removing them, and effectively changing the public burden on this collection.

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Annual Cost to Federal Government: $145,223

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 10/31/2023

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