IHS Scholarship Application Handbook - Indian Health Service

Supporting Documentation
Course Curriculum Verification
The Course Curriculum Verification (IHS-856-6) form documents
the courses that you intend to take during the upcoming academic
year. You must document your course load for the entire year (all
terms). A Curriculum for Major must be attached with this form.
Your current academic advisor/counselor or your Area Scholarship
Coordinator must review and sign your form before submission.
If you choose to have your Area Scholarship Coordinator sign your
form, you must meet with him or her by appointment for review
prior to submission.
Curriculum for Major
You are required to provide a course curriculum for your major
(available in your school catalog or your major’s department
office) and attach it to your Course Curriculum Verification
(IHS-856-6) form when submitting your application packet.
Note: Preparatory scholarship applicants must show that your curriculum for
major will permit them to gain acceptance into a Health Profession scholarship
degree program (for example, a pre-pharmacy curriculum will result in
acceptance to a pharmacy school).
If you have not been accepted for enrollment, you must submit
a Course Curriculum Verification form and a Curriculum for Major
form for each college/university to which you have applied.
Be advised that courses not required for your degree
program will not count toward determining your full-time or
part-time enrollment status.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
COURSE CURRICULUM VERIFICATION
FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: TBD
See Estimated Average Burden Time
per Response on Reverse Side.
APPLICANT’S NAME
SOCIAL SECURITY NUMBER
DEGREE PROGRAM IHS AREA OFFICE EMAIL ADDRESS
Are you applying as a: New Applicant Extension Applicant
THIS FORM MUST BE COMPLETED AND THEN SIGNED BY THE APPROPRIATE COLLEGE OR UNIVERSITY OFFICIAL
This verifies that the individual referenced above has applied for admission or is enrolled at (Name of College/University)
for the academic year 20 – 20 .
He/She will be enrolled in either a full-time or part-time (circle one) undergraduate/graduate curriculum which fulfills
the requirement for admission into his/her chosen health program identified above. The individual will be enrolled/or is
anticipated to be enrolled in the following courses commencing Fall 20 .
***ATTACH CURRICULUM FOR MAJOR FROM FIRST YEAR TO COMPLETION***
SEMESTER I / TRIMESTER I / QUARTER I (Required)
COURSE NUMBER CREDIT HOURS COURSE TITLE
TOTAL S / T / Q HOURS:
SEMESTER II / TRIMESTER II / QUARTER II (Required)
COURSE NUMBER CREDIT HOURS COURSE TITLE
TOTAL S / T / Q HOURS:
Required signature on back of this form
IHS-856-6
EF
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