Grant Reviewer Recruitment Form

INSTRUCTIONS FOR THE GRANT REVIEWER RECRUITMENT FORM

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Public Burden Statement: 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 0915-0295. Public reporting burden for this collection of information is estimated to average 45 minutes for a new reviewer and 20 minutes for an existing reviewer for the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Privacy Act Statement: Following information is provided to comply with the Privacy Act (PL 93-579). 5 U.S.C. 301 and 7 CFR 260 authorize acceptance of the information requested on this form. The data will be used to contact applicants, screen and select them to be Health Resources and Services Administration (HRSA) reviewer. Furnishing this data is voluntary.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SUBMIT IT ELECTRONICALLY TO THE ADDRESS PROVIDED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.

This is a standard form used by individuals interested in becoming Health Resources and Services Administration (HRSA) Reviewers. It will be used by HRSA to evaluate the suitability of an individual to participate in reviews of applications submitted for Federal assistance.

Item: Entry: Item: Entry:

If you have been invited to be a reviewer by HRSA Program Office/Bureau, select Program Nominated option and provide the details of the nomination. Otherwise select Self Nominated. 2a. Self-explanatory 2b. Enter maiden name if applicable 2c. Select one 2d. Select one 2e. Select one or more 2f. Employment information Employment Status: Select one Current/Last Organization Name: Enter your employer name. If retired, enter the name of your last employer. If you are currently unemployed, enter the last employer name if applicable. Self Employed persons need not answer this question. Employment Date (mm/yyyy): If you are currently employed, enter the employment month and year of start (from) date. Leave the employment end (to) date blank. Retired and Unemployed persons can enter the dates for their last employment. 2g. Enter Job Title. 2h. Self-explanatory. 2i. Self-explanatory. 2j. Enter contact information, if applicable. 2k. Select one. 2l. Indicate association with HRSA grant in any capacity. 2m. Self-explanatory. 2n. Select one. 2o. Self-explanatory. 3. 3a. Select one option to indicate whether you are affiliated with any special institutions. If affiliated, select one or more institutions: Note: HBCU – Historically Black Colleges and Universities HSI – Hispanic Servicing Institutions

3. 3b. Provide details for all your occupations. For example: Accountant, Business Owner, Financial Officer, Nurse, etc. 3c. Specialty: Indicate fields that you have worked and/or specialized in. For example: Biology, Child Care, Dental Hygiene, Family Health, etc. 3d. Indicate the settings that you have worked in. For example: Community College, Church, Government and Community Corrections Center, etc. 3e. Provided details of the licenses, board eligibility, certifications and other credentials. 3f. Enter the degree(s) earned by the applicant. 4. 4a. Select one. 4b. Select YES and specify agencies if you have reviewed for DHHS agencies such as: Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) National Institutes of Health (NIH) Substance Abuse and Mental Health Services Administration (SAMHSA) 4c. Select one option to indicate whether you have reviewed for other federal agencies. 4d. Select YES if you have served as a chairperson for any DHHS agency or any other federal/non-federal agencies. 4e. Select one option to indicate experience with faith-based institutions. If experienced, select one or more roles. 5. To be signed by the applicant indicating that all the data on this form is true and correct.

OMB Approval No: 0915-0295 Expires _____________