Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Acknowledgment Card New 1500 50 0 Form IHS-815 Acknowledgment Card
Address Change Notice New 50 1 0 Form IHS-816 Address Change Notice
Annual Status Report Modified 200 50 0 Form IHS-856-16 Annual Status Report
Application Checklist Modified 1500 200 0 Form IHS-856-2 Application Checklist
Change of Name or Address Modified 50 7 0 Form IHS-856-22 Change of Name or Address
Change of Status Modified 50 21 0 Form IHS-856-10 Change of Status
Checklist Removed 0 0 0
Course Curriculum Verification New 1500 1050 0 Form IHS-856-6 Course Curriculum Verification
Delinquent Federal Debt Modified 1500 200 0 Form IHS-856-5 Delinquent Federal Debt
Extern Site Preference Request Modified 125 17 0 Form IHS-856-17 Extern Site Preference Request
Faculty/Advisor Evaluation Modified 3000 2500 0 Form IHS-856-24 Faculty-Advisor Evaluation
Faculty/Employer Evaluation New 3000 2500 0 Form IHS-856-3 Faculty/Employer Evaluation
Faculty/Employer Evaluation Removed 0 0 0
Health Professions Contract New 225 11 0 Form IHS-818 Health Professions Contract
Lost Stipend Payment Modified 50 7 0 Form IHS-856-19 Lost Stipend Payment
Narrative Statements Modified 1500 1125 0 Form IHS-856-4 Narrative Statements
Notice of Impending Graduation Modified 200 33 0 Form IHS-856-13 Notice of Impending Graduation
Notification of Academic Problem Modified 50 7 0 Form IHS-856-9 Notification of Academic Problem
Notification of Deferment Program Modified 50 7 0 Form IHS-856-14 Notification of Deferment Program
Placement Update Modified 200 37 0 Form IHS-856-15 Placement Update
Preferred Placement Modified 200 150 0 Form IHS-856-12 Preferred Placement
Recipient's Initial Program Progress Report Modified 400 53 0 Form ihs-856-8 Recipient's Initial Program Progress Report
Request for Approval of Deferment Modified 50 7 0 Form HS-856-11 Request for Approval of Deferment
Request for Credit Validation Modified 30 3 0 Form IHS-856-23 Request for Credit Validation
Request for Extern Travel Reimbursement Modified 125 13 0 Form IHS-856-18 Request for Extern Travel Reimbursement
Request for Tutorial Assistance Modified 150 20 0 Form IHS-856-20 Request for Tutorial Assistance
Scholarship Application Modified 1500 1500 0 Form NA IHS Form 856
Scholarship Program Agreement New 175 9 0 Form IHS-817 Scholarship Program Agreement
Summer School Request Modified 75 8 0 Form IHS-856-21 Summer School Request
Verification of Acceptance or Decline of Award Modified 400 53 0 Form IHS-856-7 Verification of Acceptance or Decline of Award
Total burden requested under this ICR: 17855 9639 0  
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