Form IHS-856-13 Notification of Impending Graduation

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

FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 9/30/2020
See Estimated Average Burden Time
per Response on page 2.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

NOTICE OF IMPENDING GRADUATION
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

GRADUATION DATE (month/day/year):
COLLEGE/UNIVERSITY:
TYPE OF DEGREE:
Have you begun your job search?

Yes

No

Have you contacted an IHS recruiter, your Program Analyst or your Discipline Chief for assistance?
Have you applied for placement at an IHS, Tribal or Urban Indian Program facility?
Do you need assistance seeking placement to fulfill your service commitment?

Yes
Yes

Yes

No

No
No

COMMENTS:

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-856-13

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 10 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.