Form Application

OMB No. 0930-0255
Expiration Date: xx/xx/xxxx
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 0930-0255. Public reporting burden for this collection of information is estimated to
average 1.5 hours per respondent, per year, 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, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland,
20857.

SAMHSA, Office of Grant Review
1 Choke Cherry Road
Rockville, Maryland
USA
20857

Reviewer Contact Information
Date:

First Name:
Last Name:

Organization:

Home Address:

Title:

Home City:

Work Address:

Home State:

Work City:

Home Zip Code:

Work State:
Work Zip Code:

Home Phone:
Cell phone:

Work Phone:

Email:

Work Email:

Alternate Email:

Preferred Mailing Address:

Home

Work

Preferred Contact Number:

Home

Work

Current and Past Affiliation:

Gender:

Ethnicity:

Community Based Organization

Male

Hispanic/Latino

Consultant

Female

Not Hispanic/Latino

Consumer

Transgender

Direct Treatment for Mental Health or Substance Abuse
Faith Based Organization
Family Member of Consumer
Federal, State, and County Government
Substance Abuse Prevention
Tribal Government
Research
University, Colleges, and Other Higher Education Systems
Other

Race: (select one or more)
American Indian/Alaska Native
Asian
Black or African American
Native Hawiian or Pacific Islander
White

Primary Expertise:
DFC Reviewer
Substance Abuse Prevention
Substance Abuse Treatment
Mental Health

Secondary Expertise (only choose 5):
Target Population:

Substance and
Clinical Issues:

Related Issues:

Adolescents/Youth

Alcohol

Criminal Justice

Consumer

Antisocial Behavior

Homelessness

Consumer Supporter

Crack/Cocaine

Traumatic Stress

Consumer and Consumer Supporter

Children's Mental Health

Traumatic Stress Disorder

Disabled

Violence

Families

Co-occuring Substance Abuse
and Mental Health

Infants and Children

Criminal Behaviors

High Risk Youth

Depression/Manic Depression

Homeless

Eating Disorder

Military

Ecstasy

Military Family Members

Fetal Alcohol Syndrome

Pregnant and Postpartum Women

Heroin

Seriously Mentally ill Adults

HIV/AIDS

Veterans

Inhalents

Veterans Family Members

Marijuana

Veterans Substance Abuse and
Mental Health Issues

Medical Treatment
Methamphetamine
Methadone Treatment
Obsessive Compulsive Disorder
Personality Disorders
Post-traumatic Syndrome
Prescription Drugs
Psychotic Disorders
Suicide Prevention

Continued...

Other:

Grant Review
Experience (select one):

Counseling

Experienced SAMHSA Reviewer

Drug Courts

Experienced Federal Reviewer

Criminal Justice Program

Experienced Non-Federal Reviewer

Faith Based/Community Approaches

Limited/No Review Experience

Workplace Programs
Infrastructure
Coalition Building/Collaboration
Health Information Technology
Program Planning/Management
Research/Evaluation
Residency Training (Medical)
Training Technical Assisstance
State Systems
Other

Include a brief paragraph summarizing your general expertise in relation to substance abuse treatment, substance abuse
prevention, and mental health.