Form Approved
OMB No. 0930-0255
Approval expires: August 31, 2007
Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0255); Room 16-105, Parklawn Building; 5600 Fishers Lane, Rockville, MD 20857. 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. The OMB control number for this project is 0930-0255.
First Name: ______________________ Last Name: ____________________
Home Street Address:_____________________________________________________
Home City: ____________________ Home State: ______________ Zip Code: ______
Home Phone: (____) _____ - _________ Home Email: ______________________
Home Fax: (____) _____ - _________
Organization: ________________________________________________________
Title (If Applicable): _____________________________________________________
Work Street Address: ___________________________________________________
Work City: _____________________ Work State: _______________Zip Code_______
Work Phone: (____) _____ - _________ Work Email: ______________________
Work Fax: (____) _____ - _________
Additional Contact Number (cell phone): (____) ______- _________
Preferred Contact Method: _____ Phone _____ Email
Preferred Contact Location: ____ Home _____ Work ____ Alternate
Ethnicity ____ Hispanic/Latino
____ Not Hispanic/Latino
Race (Select one or more)
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Native Hawaiian or Other Pacific Islander
____ White
Gender ____ Male
____ Female
Professional Affiliation (Select one)
____ Community Based organization
____ Consultant
____ Consumer
____ Faith Based organization
____ Government
____ Research
____ Service Delivery
____ University
____ Other_____________________________(Specify)
Level 1 General Expertise -- Please select the one area that best describes your general expertise
____ Substance Abuse Prevention
____ Substance Abuse Treatment
____ Mental Health
Level 2 Expertise -- Please choose no more than 4 areas that describe your specific level of expertise
____ State systems
____ Research/Evaluation
____ Criminal Justice
____ Faith based and community approaches
____ Program planning/management
____ HIV/AIDS
____ Adolescents
____ Alcohol
____ Fetal Alcohol Syndrome
____ Crack/Cocaine
____ Ecstasy
____ Heroin
____ Marijuana
____ Methadone Treatment
____ Methamphetamine
____ OxyContin
____ Co-occurring Substance Abuse and Mental Health
____ Children’s Mental Health
____ Traumatic Stress
____ Seriously Mental Ill Adults
____ Violence
____ Counseling
____ Other_____________________________(Specify)
Grant Reviewing Experience (Select one)
____ Experienced SAMHSA reviewer
____ Experienced Federal reviewer
____ Experienced Non-Federal reviewer
____ Limited/No review history
Please describe your experience in grant reviewing, listed from most recent to least recent. Please include dates, location, agency and topic.
Remember to also send your resume by:
Email to: [email protected] OR
Regular mail to: SAMHSA REVIEWER OPPORTUNITIES
Office of Review
1 Choke Cherry Road
Room 3-1053
Rockville, Maryland 20857
| File Type | application/msword |
| File Title | IMMEDIATE CALL FOR REVIEWERS |
| Author | npearce |
| Last Modified By | SKING |
| File Modified | 2007-07-02 |
| File Created | 2007-07-02 |