IHS-856-10 Change of Status

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

CHANGE OF STATUS
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

See Estimated Average Burden Time
per Response on page 2.

HOME

EMAIL ADDRESS

INDICATE WHICH OF THE FOLLOWING REQUESTS APPLY TO YOU:
TRANSFER/DUAL ENROLLMENT
REASON FOR TRANSFER/DUAL ENROLLMENT:
New school has an accredited program for my degree program.
Second campus offers courses necessary to obtain my degree.
Personal/family hardship.
COMMENTS:
Read the Change of Status section of the Student Handbook for program policies related to transferring or seeking dual enrollment at
another college/university.

CHANGE IN GRADUATION DATE
CURRENT GRADUATION DATE:
NEW GRADUATION DATE:
EXPLAIN YOUR REASON(S) FOR CHANGING YOUR GRADUATION DATE:

Read the Change of Status section of the Student Handbook for program policies related to changing your graduation date.

LEAVE OF ABSENCE (LOA)
DATE LOA WILL BEGIN:

DATE LOA WILL END:

EXPLAIN YOUR REASON(S) FOR REQUESTING AN LOA:

Note: LOA requests during the first year of scholarship funding are typically not granted and will be
handled on a case by case basis.
Read the Change of Status section of the Student Handbook for program policies related to requesting an LOA.

Required signature on back of this form
IHS-856-10

EF

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 25 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.