IHS-856-7 Verification of Acceptance or Decline of Award

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

VERIFICATION OF ACCEPTANCE OR DECLINE OF AWARD

See Estimated Average Burden Time
per Response on Reverse Side.

ADDRESS

APPLICANT’S NAME

DEGREE PROGRAM

IHS AREA OFFICE

EMAIL ADDRESS

Please indicate your acceptance or decline of an Indian Health Service scholarship award by checking the
appropriate space below. Your scholarship award will not be issued until this form is completed and returned.
I accept the scholarship award for the 20

– 20

school year.

I decline the scholarship award for the 20

– 20

school year.

If you choose to accept this award, you must immediately provide us below with your permanent mailing address to
which correspondence will be sent during the entire first year of scholarship funding.
Please complete the following information.
STREET ADDRESS / POST OFFICE BOX NUMBER

CITY

STATE

ZIP CODE

Please note this is a change of address

APPLICANT’S SIGNATURE

IHS-856-7

DATE

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 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.