Form IHS-856-14 Notification of Deferment Program

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

FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 10/31/2023
See Estimated Average Burden Time
per Response on page 2.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

DEFERMENT APPROVAL REQUEST
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

This document notifies the IHS Scholarship Program of your selected residency/training program,
if approved this will delay the service commitment incurred under 25 U.S.C. 1613a and pursuant to your Contract with IHS.

POST-GRADUATE CLINICAL TRAINING PROGRAM:
PROGRAM DIRECTOR (Name):
PROGRAM ADDRESS:
CITY

STATE

PHONE

LENGTH OF PROGRAM:

ZIP CODE

EMAIL ADDRESS

START DATE

END DATE

DATE AVAILABLE TO BEGIN SERVICE COMMITMENT:

EMERGENCY CONTACT INFORMATION
NAME

ADDRESS

PHONE: CELL

CITY

STATE

RECIPIENT’S SIGNATURE

HOME

ZIP CODE

DATE

Return to:
Indian Health Service
Scholarship Program
5600 Fishers Lane
Mail Stop: OHR (11E53A)
Rockville, MD 20857
Reviewed (IHS use only):

Approved (IHS use only):
Analyst, Branch Chief or Designee

IHS-856-14

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 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, Scholarship Program, 5600 Fishers Lane,
Mail Stop: OHR (11E53A), Rockville, MD 20857.