Form Approved
OMB No. 0930-0255
Approval expires: September 30, 2010
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.
TPreferred FedEx Mailing Location:T Home Work Alternate
TPreferred Daytime Contact Number:T Home Work Alternate
TFirst Name: ______________________ Last Name: _________________
THome Street Address:_________________________________________
THome City: ____________________ Home State: ______________
TZip Code: ______
THome Phone: (____) _____ - _________
THome Email: ______________________
THome Fax: (____) _____ - _________
TOrganization: ______________________________________________
TTitle (If Applicable): __________________________________________
TWork Street Address: _________________________________________
TWork City: _____________________ Work State: ______________
TZip Code_______
TWork Phone: (____) _____ - _________
TWork Email: ______________________
TWork Fax: (____) _____ - _________
TAdditional Contact Number (cell phone): (____) ______- _________
TPreferred Contact Method: ____ Phone ____ Email
TPreferred 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
Education Level (Select one)
____ High School
____ Some College
____ College
____ Some Graduate School
____ Master’s Degree
____ Ph.D.
Professional Affiliation (Select one)
____ Community Based organization
____ Consultant
____ Faith Based organization
____ Government
____ Research
____ Service Delivery
____ University
____ Other_____________________________ (Specify)
Other ____ Consumer
____ Family Member of Consumer
General Expertise -- Please select the one area that best describes your general expertise
____ Substance Abuse Prevention
____ Substance Abuse Treatment
____ Mental Health
Expertise -- Please choose no more than 4 areas that best describe your specific 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 Mentally ill Adults
____ Violence
____ Counseling
____ Coalition Building/Collaboration
____ Families
____ Homelessness
____ Residency Training (Medical)
____ Suicide Prevention
____ Training/Technical Assistance
____ Veterans Substance Abuse/Mental Health Issues
____ Veterans Family Members
____ Consumer (have experienced treatment and recovery)
____ Consumer supporter (provide support in a nonprofessional capacity)
____ Consumer AND consumer supporter
____ 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 | csweeney |
| File Modified | 2010-06-04 |
| File Created | 2010-06-04 |