IHS-856-14 Notification of Deferment Intent

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

NOTIFICATION OF DEFERMENT INTENT
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

IHS AREA OFFICE

See Estimated Average Burden Time
per Response on page 2.

PHONE: CELL

HOME

EMAIL ADDRESS

Please identify the health profession discipline and post-graduate clinical training program or residency specialty that
you will be pursuing. On page 2, please include information on the program(s) to which you will apply.
Please read the Post-Graduate Clinical Training section of the Service Commitment Handbook for more information.
REQUIRED PROGRAMS
Physicians, social workers, clinical psychologists, dietitians and podiatrists are required to complete additional post-graduate
training and licensure before they can begin their service commitment.
Physician
Three Years
Four Years
Five Years
Family Practice/Psychiatry
Emergency Medicine
Anesthesiology
General Surgery
Family Practice
Emergency Medicine
General Internal Medicine
General Psychiatry
Internal Medicine/Psychiatry
Internal Medicine/Family Practice
General Pediatrics
Internal Medicine/Pediatrics
Obstetrics/Gynecology
Clinical Psychologist
2,000-hours supervised practice under a licensed clinical psychologist. Please specify required hours and attach
a copy of state licensure requirements.
Social Worker
2,000 – 3,000 hours supervised practice under a licensed social worker. Please specify required hours and attach
a copy of state licensure requirements.
Dietitian
1,200-hour Accreditation Council for Education in Nutrition and Dietetics (ACEND)-approved internship under the
supervision of a registered dietitian (if not included in your school’s didactic instruction).
Podiatrist
Three-year resource-based, competency-driven, assessment-validated program that consists of training in inpatient
and outpatient medical and surgical management and approved by the Council on Podiatric Medical Education (CPME).
OPTIONAL PROGRAMS
Pharmacists, optometrists, nurses and dentists can elect to complete one year of post-graduate training upon receiving
IHS Scholarship Program approval.
Pharmacist
One-year IHS pharmacy residency, American Society of Health-System Pharmacists (ASHP) or American Pharmacists Association
(APhA) accredited Post-Graduate Year One (PGY1) Pharmacy Residency Program (Hospital, Community or Managed Care only).
Optometrist
One-year Ocular Disease/Pathology or Primary Care Optometry residency program.
Nurse
One-year training program with an emphasis on clinical out-patient (OPD), in-patient (IPD) and/or emergency (ERD) nursing skills.
Dentist
One-year Advanced Education Program in General Dentistry or General Practice Residency. Only programs that are fully
operational with the American Dental Asociation Commission on Dental Accreditation (ADA CODA) status are permitted.
Required signature on back of this form
IHS-856-11

EF

Program 1
NAME OF FACILITY

ADDRESS

PROGRAM DIRECTOR

PHONE

EMAIL ADDRESS

PHONE

EMAIL ADDRESS

PHONE

EMAIL ADDRESS

Program 2
NAME OF FACILITY

ADDRESS

PROGRAM DIRECTOR

Program 3
NAME OF FACILITY

ADDRESS

PROGRAM DIRECTOR

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
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 8 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.