Osers Peer Reviewer Data Form

OMB NO: 1820-0583 Expiration 5/31/2008

OSERS PEER REVIEWER DATA FORM

Thank you for your interest in being a peer reviewer for the Office of Special Education and Rehabilitative Services (OSERS). By responding to the following questions, you can assist us in making appropriate selections for peer review panels. The statement asks for demographic information about yourself. If possible, we ask that you transmit the form electronically to OSERS Peer Reviewer email address at: [email protected]. Please type or print your answers. We appreciate your time in completing this form.

1. Dr./Mr./Mrs./Ms.

First Name Middle Initial Last Name Ms.

2. Gender:  Male  Female

3. Home Address:

P.O. Box

Street

City, State & Zip Code

Phone Number TDD Number

Fax Number E-mail Address

4. Work/Alternate Address:

Employer ____________________________________________________________________

Department __________________________________________________________________

Position Title ________________________________________________________________

P.O. Box

Street

City, State & Zip Code

Phone Number TDD Number

Fax Number E-mail Address

Please check one address (home or work/alternate) for each type of correspondence.

Financial Address	Address where financial documents (e.g., 1099’s, honorarium and per diem checks) will be sent.	 Home  Work/Alternate
FedEx Address	Address where confirmation packets, applications, and airline tickets will be sent. Must include a street (i.e., cannot be a P.O. Box).	 Home  Work/Alternate
Roster Address	Address that will appear on the panel roster for dissemination to other peer reviewers.	 Home  Work/Alternate

5. Ethnicity: Are you (select only one)

 Hispanic or Latino

 Not Hispanic or Latino

Race: Are you (select one or more)

 American Indian or Alaska Native

 Native Hawaiian or other Pacific Islander

 Asian Native Hawaiian or other Pacific Islander

 Black or African American

 White

6. Disability:

Please check box(es) if you are:

 Individual with a Disability

 Spouse/Partner of an Individual with a Disability

 Parent of an Individual with a Disability-

a. Please provide the birth date of your youngest Child with a Disability

 Sibling of an Individual with a Disability

(Any reasonable accommodations required by reviewers

will be provided.)

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1820-0583. The time required to complete this information is estimated to average .30 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate (s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Office of Special Education and Rehabilitative Service, Grants and Contracts Services Team, Attn: Lewis Medley , 400 Maryland Avenue, S.W. Washington, D.C. 20202-2550.