Circular 95-12 Exhibit D

1. Date of request for documents(s):

2. Name, phone number, OIG Office and address of OIG representative requesting IHS documents:

3. Documents(s) requested (attach a second sheet if more room is needed):

4. _____Yes _____No These documents are complete and may be sent to the OIG without review by another IHS Office.

5. If you recommend review of documents by another IHS Office or the Director of Headquarters Operations, please list:  1) office(s) that should review the document, 2) reason(s) for the recommended review.

   Offices to Review	Reason(s) for Review
   1.	1.
   2.	2.
   3.	3.

   _____________________________/_________ Signature Date _____________________________/_________ Division Office

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