Form 1 ANA Consultant and Evaluator Qualification Form

Administration for Native Americans

ANA Consultant and Evaluator Qualifications Form

The Paperwork Reduction Act of 1995: Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 number.

Date of completion of form:      

1. General Information

1.1 Please Check which position you are applying for: T/TA Provider Grant Evaluator
1-2. First Name:      
1-3. Last Name:      
1-4. Mailing Address:      
1-5. City:      	1-6. State:      			1-7. Zip Code:      
1-8. Physical Address if different from above. (FedEx or Courier Delivery):      
1-9. City:      	2-0. State:      			2-1. Zip Code:      
1-12. Home Phone:      			1-13. Cell Phone:      
1-14. Work Phone:      		Extension:      	1-15. Fax:      
1-16. Email:      

Office Use Only

Date Received by Master Key Consulting:      

Last Updated:      

2. Grant Evaluator Experience

2-1. Have you previously Served as evaluator for ANA? (If yes, please answer questions 2-2 and 2-3 otherwise skip to question 2-4) Yes No
2-2. What Fiscal Years did you serve as an ANA evaluator (Mark all that apply): 2002 2003 2004 2005 2006 2007 2008 2009 2010
2-3. What Program Areas served as an ANA evaluator (Mark all that apply): SEDS NL NR NM NI
2-4. Have you ever served as a grant evaluator for organizations other than ANA (If yes, answer 2-5 otherwise skip to section 3? Yes No
2-5. Fiscal Year(s):      	Agency or Organization:      
Type of Grant/Contract (specify program if known):      
Reference: Name of contact person at this agency:      
Reference: Phone      
Reference: Email      
Population served by Grants/Contract (Mark all that apply): American Indian Alaska Native Native Hawaiian Native American Pacific Islanders Other (please describe):      
2-5. Fiscal Year(s):      	Agency or Organization:      
Type of Grant/Contract (specify program if known):      
Reference: Name of contact person at this agency:      
Reference: Phone      
Reference: Email      
Population served by Grants/Contract (Mark all that apply): American Indian Alaska Native Native Hawaiian Native American Pacific Islanders Other (please describe):      

3. ANA Areas of Interest or Expertise

3-1. Identify the areas that you consider yourself qualified to serve as an ANA Proposal Reviewer (Mark all that apply):

SEDS: Governance

SEDS: Social Development

SEDS: Economic Development

Native American Language Preservation and Maintenance

Environmental Regulatory Enhancements

Environmental Mitigation

Native American Healthy Marriage Initiative

4. Demographic Information

4-1. Native American Heritage (Mark all that apply):

Enrolled member of a federally recognized tribe (specify):      

Enrolled member of a non-federally recognized tribe (specify):      

Native Hawaiian

Native American Pacific Islander (specify):      

Other Native American (specify):      

Other: Caucasian

Other: African American

Other: Hispanic

Other: Asian, other than Pacific Islander and Native Hawaiian
Multiracial

4-2. Current Place of Residence:

Living on reservation

Living near reservation (within 10 miles)

Non-reservation (urban)

Non-reservation (rural)

Indian territory

Alaskan Native Village

Pacific Island, living on homestead

Pacific Island, living off homestead

4-3. Number of years at this residence:      

5. Experience and Skills

5-1. Check the areas in which you have 3 or more years of experience.
Agriculture Crops Dairy Fisheries Livestock/poultry Other:       Arts/Language Music Tribal culture/traditions-general Tribal Languages Visual Arts Other:       Communications Media (Radio/TV) Public Relations Other:       Education Education Administration K-12 Teaching Higher Education Teaching Vocational or Technical Education Other:       Environment Conservation Forestry Land Management Recycling or Waste Management Water Management Other:      	Financial/ Administration/Legal Accounting Banking or credit union Contracts or grants management Economics Financial management/analysis Human Resources/training Import/export Insurance Investment Legal Services Organizational development – private sector Organizational development – public sector Tax Code Uniform commercial codes Other:       Manufacturing/Production Handicrafts Other:       Public Administration Federal Government State Government Local Government Tribal Administration Tribal Legislature Tribal Courts Tribal, other:       Other:      	Service Sector E-commerce Food Service Health Care Hospitality/tourism Marketing/promotion Personal Services Wholesale/retail Social Services Child Welfare Child Care and Development Disability Services Head Start Violence Prevention Youth Development Technical Architecture Automotive Basic Sciences/research Construction Trades Engineering Graphic Arts Library Sciences Printing Transportation Utilities Other:       Technology Computer Hardware Computer Software Electronics Energy Public Services Telecommunications Other:      

6. Experience in Providing Training and Technical Assistance

6-1. Have you ever provided technical assistance and or training (T/TA) to the Native American community (If No, skip to section 7)?

Yes No

6-2. In what capacity did you provide T/TA?

Individual Consultant

As part of fulltime employment

Other (please specify):      

6-3. Identify the recipient of the T/TA:

Individual members/group of a tribe or tribes (e.g., Tribal Legislature)

Individual Tribe(s) generally

Cluster of Tribes

Other (please specify):      

6-4. Identify the funding sources for the T/TA you provided:

ANA

IHS

BIA

DOJ

State Agency

Tribal Organization

Other Federal Agency (please specify):      

Other DHHS Agency (please specify):      

Other (please specify):      

6-5. Are you currently providing T/TA to the Native American Community?

Yes No

7. Computer Capability

7.1 Please mark all the computer software programs with which you have at least one year’s experience:

Microsoft Word

Microsoft Access

Microsoft Excel

Other (please specify):      

Note: A current resume must be submitted with this application to be considered for an ANA proposal reviewer position. Email resume to [email protected] or mail to Administration for Native Americans Mail Stop 8th F1. West Aerospace Center 370 L'Enfant Promenade Washington, D.C. 20447-0002

OMB Approval Number xxxx-xxxx

Expires xx/xx/xxxx