Fillable Printable Request For Approval Of Deferment
Fillable Printable Request For Approval Of Deferment
Request For Approval Of Deferment
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
REQUEST FOR APPROVAL OF DEFERMENT
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
Please identify the health profession discipline and post-graduate clinical training program or residency specialty that
you will be pursuing. On page 2, please include information on the program(s) to which you will apply.
Please read the Post-Graduate Clinical Training section of the Service Commitment Handbook for more information.
REQUIRED PROGRAMS
Physicians, social workers, clinical psychologists, dietitians and podiatrists are required to complete additional post-graduate
training and licensure before they can begin their service commitment.
Physician
Three Years
Emergency Medicine
Family Practice
General Internal Medicine
General Pediatrics
Four Years
Anesthesiology
Emergency Medicine
General Psychiatry
Internal Medicine/Family Practice
Internal Medicine/Pediatrics
Obstetrics/Gynecology
Five Years
Family Practice/Psychiatry
General Surgery
Internal Medicine/Psychiatry
Clinical Psychologist
2,000-hours supervised practice under a licensed clinical psychologist. Please specify r equired hours and attach
a copy of state licensure requirements.
Social Worker
2,000 – 3,000 hours supervised practice under a licensed social worker . Please specify required hours and attach
a copy of state licensure requirements.
Dietitian
1,200-hour Accr editation Council for Education in Nutrition and Dietetics (ACEND)-approved internship under the
supervision of a registered dietitian (if not included in your school’s didactic instruction).
Podiatrist
Thr ee-year resource-based, competency-driven, assessment-validated program that consists of training in inpatient
and outpatient medical and surgical management and approved by the Council on Podiatric Medical Education (CPME).
OPTIONAL PROGRAMS
Pharmacists, optometrists, nurses and dentists can elect to complete one year of post-graduate training upon receiving
IHS Scholarship Program approval.
Pharmacist
One-year IHS pharmacy residency, American Society of Health-System Pharmacists (ASHP) or American Pharmacists Association
(APhA) accredited Post-Graduate Year One (PGY1) Pharmacy Residency Program (Hospital, Community or Managed Care only).
Optometrist
One-year Ocular Disease/Pathology or Primary Care Optometry residency program.
Nurse
One-year training pr ogram with an emphasis on clinical out-patient (OPD), in-patient (IPD) and/or emergency (ERD) nursing skills.
Dentist
One-year Advanced Education Pr ogram in General Dentistry or General Practice Residency. Only programs that are fully
operational with the American Dental Asociation Commission on Dental Accreditation (ADA CODA) status are permitted.
Required signature on back of this form
IHS-856-11 EF
Program 1
NAME OF FACILITY
ADDRESS
PROGRAM DIRECTOR PHONE EMAIL ADDRESS
Program 2
NAME OF FACILITY
ADDRESS
PROGRAM DIRECTOR PHONE EMAIL ADDRESS
Program 3
NAME OF FACILITY
ADDRESS
PROGRAM DIRECTOR PHONE EMAIL ADDRESS
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
Approved (IHS use only):
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.
