Form IHS-856-10 Change of Status

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

FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 10/31/2023

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

CHANGE OF STATUS
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

See Estimated Average Burden Time
per Response on page 2.

HOME

EMAIL ADDRESS

INDICATE WHICH OF THE FOLLOWING REQUESTS APPLY TO YOU:
TRANSFER/DUAL ENROLLMENT
REASON FOR TRANSFER/DUAL ENROLLMENT:
New school has an accredited program for my degree program.
Second campus offers courses necessary to obtain my degree.
Personal/family hardship.
COMMENTS:
Read the Change of Status section of the Student Handbook for program policies related to transferring or seeking dual enrollment at
another college/university.

CHANGE IN GRADUATION DATE
CURRENT GRADUATION DATE:
NEW GRADUATION DATE:
EXPLAIN YOUR REASON(S) FOR CHANGING YOUR GRADUATION DATE:

Read the Change of Status section of the Student Handbook for program policies related to changing your graduation date.

LEAVE OF ABSENCE (LOA)
DATE LOA WILL BEGIN:

DATE LOA WILL END:

EXPLAIN YOUR REASON(S) FOR REQUESTING AN LOA:

Note: LOA requests during the first year of scholarship funding are typically not granted and will be
handled on a case by case basis.
Read the Change of Status section of the Student Handbook for program policies related to requesting an LOA.

Required signature on back of this form
IHS-856-10

EF

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):

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

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 25 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.