Form IHS-856-15 Placement Update

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

PLACEmENT UPDATE
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

IHS AREA OFFICE

Home

EMAIL ADDRESS

Site Placement
Have you been placed at an approved IHS, Tribal or Urban facility?

Yes

No

If yes, provide the:
Name of Facility:
Position Title:
Start Date:
If no, please attach documentation of your efforts to secure placement (e.g., proof of application/rejection). You must submit another
Placement Update form in 30 days providing further information on your efforts to begin your service obligation.
If you have reached the 90 day limit and have not accepted placement at one of your preferred sites, or cannot find employment,
the Director of IHS may involuntarily place you at an Indian health facility based on the needs of the IHS.

Graduation Date:
College/University:
Degree Obtained:
NOTE: You should have already submitted these forms to your IHS Scholarship Program analyst:
OF 612 — Optional Application for Federal Employment or Commissioned Corps Application (PHS Form 50)
Preferred Placement (IHS-856-12)
POSITIONS APPLIED FOR (Rejection Letters Attached):
Vacancy Announcement No./Title/Location:
Vacancy Announcement No./Title/Location:
Vacancy Announcement No./Title/Location:
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-856-15

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 11 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.