Form HS-856-11 Request for Approval of Deferment

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

See Estimated Average Burden Time
per Response on Reverse Side.

Request for Approval of Deferment
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

CAREER CATEGORY

PHONE: CELL

IHS AREA OFFICE

Home

EMAIL ADDRESS

Below is a list of required/optional post-graduate clinical training programs and residencies for which recipients are
required to request deferment of their service obligation. Please check the type program(s) or residency(s) where you
will be submitting an application.
If the post-graduate clinical training program(s) or residency(s) is not listed, please provide information regarding the
program(s) or residency(s) under the section titled “Other.”
Physician
Three Years
Emergency Medicine
Family Practice
General Internal Medicine
General Pediatrics

Four Years
General Psychiatry
Internal Medicine/Pediatrics
Internal Medicine/Family Practice
Obstetrics – Gynecology

Five Years
Anesthesiology
General Surgery

Fellowship
Trauma-Critical Care

Clinical Psychologist
2,000-hour supervised practice under a licensed clinical psychologist
Social Worker
2,000-hour supervised practice under a licensed clinical social worker
Dietitian
900-hour American Dietetic Association (ADA)-approved internship (if not included in your school’s didactic instruction)
Pharmacist
One-year American Society of Health-System Pharmacists (ASHP) or American Pharmacists Associations (APhA)
accredited Post-Graduate Year One (PGY 1) Pharmacy Residency Program (hospital, community or managed care only)
Optometrist
One-year post-graduate residency program for Ocular Disease/Pathology or Primary Care Optometry
OTHER:

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-856-11

Approved (IHS use only):
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, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.