IHS-856-21 Summer School Request

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

SUMMER SCHOOL REQUEST
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

SCHOLARSHIP:

See Estimated Average Burden Time
per Response on page 2.

HOME

EMAIL ADDRESS

Preparatory

Pre-Graduate

TYPE OF SUMMER SCHOOL REQUEST:
ENROLLMENT STATUS:

Full-time

Health Professions

Year Round Curriculum
Repeat/Curriculum Required Course Work
Part-time

EXPLAIN YOUR REQUEST FOR APPROVAL TO ATTEND SUMMER SCHOOL:

YEAR ROUND CURRICULUM
(Please include all courses required)

SUMMER SESSION I:
COURSE NUMBER

FROM

SUMMER SESSION II:
COURSE NUMBER

TO

TITLE

HRS.

FROM
TITLE

TO
HRS.

Required signature on back of this form
IHS-856-21

EF

REPEAT/CURRICULUM REQUIRED COURSE WORK
(Please include all courses required)

SUMMER SESSION I:
COURSE NUMBER

FROM

HRS.

SUMMER SESSION II:
COURSE NUMBER

TO

TITLE

FROM

TO

TITLE

HRS.

FUNDING REQUESTED (Must include tuition amount for each session):
SUMMER SESSION I

SUMMER SESSION II

TUITION
FEES
TOTAL

YOU MUST SUBMIT DOCUMENTATION TO SUBSTANTIATE THESE COURSE REQUIREMENTS.

RECIPIENT’S SIGNATURE

DATE

ADVISOR’S NAME (Print)

DATE

ADVISOR’S SIGNATURE

PHONE:

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

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0917-0006. This information collection is for the purposes of the Indian Health Service
Scholarship Program to provide Preparatory, Pre-graduate, and Health Professions Scholarships to students
pursuing health professions education and training and the information collected will be used to identify
qualified American Indian/Alaska Native students. The time required to complete this information collection is
estimated to average less than 6 minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, to review and complete the information collection. This
information collection is required to obtain or retain a benefit (25 U.S.C. § 1613 and 25 U.S.C. § 1613a) and is
subject to Privacy Act safeguards, 5 U.S.C. § 552a(e)(4) and the nature and extent of confidentiality is set
forth in the Privacy Act and SORN # 09-17-0002, described at 74 FR 50222 (September 30, 2009). If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: Indian Health Service, IHS Information Collections Clearance Officer, 5600 Fishers Lane, Mail stop: 09E70,
Rockville, MD 20857.