IHS-856-16 Annual Status Report

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

ANNUAL STATUS REPORT
RECIPIENT’S NAME

See Estimated Average Burden Time
per Response on page 2.

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

ASSIGNMENT:

Indian Health Service

Urban Indian Health Program

Private Practice

Tribal Facility

NAME OF FACILITY

ADDRESS

MY CURRENT POSITION TITLE:
FIRST DAY OF PRACTICE:
YEARS REMAINING OF SERVICE COMMITMENT:
You are required to submit a leave report summary, provided by your local Human Resources Department,
with this form documenting your leave taken over the past 12 months of employment.

COMMENTS:

EMPLOYEE’S SIGNATURE

DATE

SUPERVISOR’S TITLE (Print)

PHONE

SUPERVISOR’S SIGNATURE

DATE

Reviewed (IHS use only):
Analyst, Branch Chief or Designee
IHS-856-16

EF

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 15 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..