Fillable Printable Public Law 94-437 ? Title I Scholarship Program Extern Site Preference Request

Public Law 94-437 ? Title I Scholarship Program Extern Site Preference Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

INDIAN HEALTH SERVICE

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

EXTERN SITE PREFERENCE REQUEST

FORM APPROVED:

OMB Approval No: 0917-0006

Exp. Date: 3/31/2020

See Estimated Average Burden Time

per Response on page 2.

RECIPIENT’S NAME DEGREE PROGRAM

ADDRESS PHONE: CELL HOME

IHS AREA OFFICE EMAIL ADDRESS

ARE YOU AN IHS SCHOLARSHIP RECIPIENT? YES NO

GRADUATION DATE: CURRENT GPA:

COLLEGE/UNIVERSITY:

DATES AVAILABLE FOR EXTERN ASSIGNMENT: FROM TO

DESCRIBE THE TYPE OF EXTERN ASSIGNMENT YOU DESIRE:

EXTERN SITE PREFERENCE

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

Albuquerque

Anchorage

Bemidji

Billings

California

Great Plains

Nashville

Navajo

Oklahoma City

Phoenix

Portland

Tucson

INDICATE YOUR PREFERRED IHS OR TRIBAL HOSPITAL/CLINIC FOR EXTERNSHIP:

(1) (2)

(3) (4)

COMMENTS:

Upload your completed form before submitting your externship application through USAJOBS.

Read the Student Handbook or visit ihs.gov/scholarship for information on the externship application process.

SIGNATURE DATE

Reviewed (IHS use only):

Extern Coordinator, Branch Chief or Designee

IHS-856-17 EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE

Public reporting burden for this collection of information is estimated to average 8 minutes per response including

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,

and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a

person is not required to respond to, a collection of information unless it displays a currently valid OMB control

number. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing this burden to Indian Health Service, Scholarship Program, 5600 Fishers Lane,

Mail Stop: OHR (11E53A), Rockville, MD 20857.