Form IHS-856-12 Preferred Placement

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

PREFERRED PLACEMENT

RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

BACKGROUND
GRADUATION DATE:
DEGREE OBTAINED:
COLLEGE/UNIVERSITY:
DESCRIBE YOUR PREFERRED WORK ASSIGNMENT:

MY SERVICE COMMITMENT IS FOR A PERIOD OF

YEARS.

INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR PLACEMENT:

Albuquerque

California

Oklahoma City

Anchorage

Great Plains

Phoenix

Bemidji

Nashville

Portland

Billings

Navajo

Tucson

INDICATE YOUR PREFERRED IHS, TRIBAL OR URBAN INDIAN PROGRAM FACILITY TO COMPLETE YOUR SERVICE COMMITMENT:

(1)

(4)

(2)

(5)

(3)

(6)

I understand that I must submit a position description at my chosen Indian health facility for review and approval by the IHS Scholarship Program before
beginning to fulfill my service commitment.
RECIPIENT’S SIGNATURE

DATE

Return to:
Indian Health Service

Scholarship Program

5600 Fishers Lane

Mail Stop: OHR (11E53A)

Rockville, MD 20857

Reviewed (IHS use only):
Analyst, Branch Chief or Designee
IHS-856-12

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 30 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.