IHS-856-8 Progress 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
See Estimated Average Burden Time
per Response on page 2.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

RECIPIENT’S INITIAL PROGRAM PROGRESS REPORT
RECIPIENT’S NAME

DEGREE PROGRAM

ADDRESS

PHONE: CELL

IHS AREA OFFICE

HOME

EMAIL ADDRESS

SCHOLARSHIP:

Preparatory

Pre-Graduate

Fall

Winter

Spring

Semester

Quarter

Trimester

Full-time

Part-time

ACADEMIC TERM:

ENROLLMENT STATUS:

Health Professions
Summer

CLASS ENROLLMENT: Attach an official university printout of the courses in which you are currently enrolled or list
the courses below.
COURSE NUMBER

COURSE TITLE

HRS.

COURSE NUMBER

COURSE TITLE

HRS.

I will participate in the following special activities in my school or community:

I have encountered the following problems with my school, community or scholarship:

Activities that will affect my status in the coming months include:

Required signature on back of this form
IHS-856-8

EF

Additional comments:

STUDENT’S SIGNATURE

DATE

ADVISOR OR REGISTRAR NAME (Print)

POSITION TITLE

ADVISOR OR REGISTRAR SIGNATURE

DATE

PHONE: CELL

OFFICE

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 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.