OSERS Peer Review Data Form

OMB NO: 1820-0583

Expiration 08/31/2014

Office of Special Education and Rehabilitative Services

Peer Reviewer Data Form

Thank you for your interest in being a peer reviewer for the Department of Education, Office of Special Education and Rehabilitative Services (OSERS). By responding to the following questions you can assist us in making appropriate selections for equitable peer review panels. Send the completed form and current resume to OSERS Peer Reviewer email address at: [email protected]. We appreciate your time in completing this form.

First Submission

Update to Previous Submission

(Complete section 1 plus any section needing updates)

1. Mr. Mrs. Ms.

First Name      

Middle Initial      

Last Name      

Suffix (i.e. Jr., III)      

2. Gender: Male Female

3. Home Address:

P.O. Box      

Street      

City, State & Zip Code      

Phone Number      

TDD Number      

Fax Number      

E-mail Address      

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. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number 1820-0583. Note: Please do not return the completed OSERS Peer Reviewer Data Form to this 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      

5. List Educational Degrees and Areas of Expertise, including any experience reviewing Federal discretionary grant applications:      

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/Alt.
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/Alt.
Roster Address	Address that will appear on the panel roster for dissemination to other peer reviewers.	Home Work/Alt.

6. 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

Black or African American

White

7. Disability: Please select any that apply:

Individual with a Disability

Spouse/Partner of an Individual with a Disability

Parent of an Individual with a Disability

Birth date of your youngest Child with a Disability      

Sibling of an Individual with a Disability

Any reasonable accommodation required by reviewers will be provided.

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