IHS-856-12 Preferred Placement

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

INDIAN HEALTH SERVICE

FORM
APPROVED:

OMB
Approval
No:
0917-0006

Exp.
Date:
10/31/2023
See Estimated Average Burden Time
per Response on page 2.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

PREFERRED PLACEMENT

RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

BACKGROUND
GRADUATION DATE:
DEGREE OBTAINED:
COLLEGE/UNIVERSITY:
DESCRIBE YOUR PREFERRED WORK ASSIGNMENT:

MY SERVICE COMMITMENT IS FOR A PERIOD OF

YEARS.

INDICATE BY PRIORITY THE PREFERRED IHS AREA/PROGRAM LOCATION FOR PLACEMENT:

Albuquerque

California

Oklahoma City

Anchorage

Great Plains

Phoenix

Bemidji

Nashville

Portland

Billings

Navajo

Tucson

INDICATE YOUR PREFERRED IHS, TRIBAL OR URBAN INDIAN PROGRAM FACILITY TO COMPLETE YOUR SERVICE COMMITMENT:

(1)

(4)

(2)

(5)

(3)

(6)

I understand that I must submit a position description at my chosen Indian health facility for review and approval by the IHS Scholarship Program before
beginning to fulfill my service commitment.
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-856-12

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 30 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.