Form 1 EHS Expansion and EHS-CC Partnerships Survey

Office of Head Start and Office of Child Care Reviewer Availability Request for
the Early Head Start Expansion and Early Head Start-Child Care Partnerships Grant
Review
OMB Control Number: 0970-0477
Expiration Date: 3/31/2019 Information Collection for Specific Reviews

The Administration for Children and Families (ACF), Office of Head Start (OHS) and Office
of Child Care (OCC) request your availability to participate in the objective review of Early
Head Start Expansion and Early Head Start-Child Care Partnerships grant
applications. Your reply is requested by 5:00 P.M. (EST) on XXX.

* 1. Please provide your contact information.
Name
City/Town
State/Province

-- select state --

Email Address
Phone Number

* 2. Are you currently employed by a Head Start, Early Head Start, or Early Head Start-Child Care
Partnerships grantee?
Yes
No

Office of Head Start and Office of Child Care Reviewer Availability Request for
the Early Head Start Expansion and Early Head Start-Child Care Partnerships Grant
Review
OMB Control Number: 0970-0477
Expiration Date: 3/31/2019 Information Collection for Specific Reviews

Reviewer Availability
* 3. If you are available to participate in the 2016 Early Head Start Expansion and Early Head StartChild Care Partnerships grant reviews, please indicate which dates you are available.
September 23 - September 30, 2016
September 30 - October 7, 2016
October 7 - October 14, 2016
October 14 - October 21, 2016
October 21 - October 28, 2016
October 28 - November 4, 2016
November 4 - November 11, 2016
November 11 - November 18, 2016
I am no longer interested in serving as a grant reviewer. Please update my profile.

Office of Head Start and Office of Child Care Reviewer Availability Request for
the Early Head Start Expansion and Early Head Start-Child Care Partnerships Grant
Review
OMB Control Number: 0970-0477
Expiration Date: 3/31/2019 Information Collection for Specific Reviews

Experience
* 4. Do you have professional experience with a Head Start or Early Head Start program?
Yes
No

* 5. Do you have professional experience with an American Indian/Alaskan Native program?
Yes
No

* 6. Do you have professional experience with a Migrant and Seasonal Head Start program?
Yes
No

* 7. Do you understand or have you participated in planning and/or implementing Child Care and
Development Fund subsidy policy to comply with the Child Care and Development Block Grant Act
Reauthorization Act of 2014?
Yes
No

* 8. Do you have experience using ACF's Application Review Module (ARM) in the past three years?
Yes
No

* 9. Have you participated in an OHS and/or ACF panel review in the past two years?
Yes
No

10. If you have served on an OHS and/or ACF panel review in the past two years, please identify the
review(s) in which you participated and the role(s) in which you served.
Panelist Role
Designation Renewal
System
Replacement Grants
Early Head Start-Child
Care Partnerships
Early Head Start
Expansion
National Technical
Assistance Centers
Other

Office of Head Start and Office of Child Care Reviewer Availability Request for
the Early Head Start Expansion and Early Head Start-Child Care Partnerships Grant
Review
OMB Control Number: 0970-0477
Expiration Date: 3/31/2019 Information Collection for Specific Reviews

ACF Voluntary Self-Identification Question
11. The Administration for Children and Families, U. S. Department of Health and Human Services is
committed to increasing the diversity of the non-Federal peer reviewers utilized in the competitive
grants review process to the extent permitted by law. You can help us achieve this goal by
voluntarily self-identifying -- please indicate your race and/or ethnic heritage by checking the
appropriate box below. Please note that this question utilizes the standard Federal identification
categories. Your assistance is invaluable in enabling the agency to promote broad representation,
especially for underserved and underrepresented groups and track our progress on this important
goal. The question is voluntary and will not be used in the selection of grant reviewers for
Administration for Children and Families’ discretionary grant programs. This information will be
used solely to monitor the diversity of our grant reviewer pool.

American Indian or Alaskan Native

Hispanic

Asian or Pacific Islander

White, not of Hispanic origin

Black, not of Hispanic origin

Public reporting burden of this collection of information is estimated to average 10 minutes 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. 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.

Office of Head Start and Office of Child Care Reviewer Availability Request for
the Early Head Start Expansion and Early Head Start-Child Care Partnerships Grant
Review
OMB Control Number: 0970-0477
Expiration Date: 3/31/2019 Information Collection for Specific Reviews

Thank you for completing the survey!

Please Note: An affirmative response to the request for availability will not guarantee placement on a
review panel. The request for availability of review participants is based on the projected number of
applications eligible for review. If the number of applications received is less than projected, some
reviewers may not be utilized or may be asked to participate in an Alternate / Stand-by role. If you have
any questions or concerns, please contact us directly at 1-888-242-0684 and press "2" for reviewer
support. You may also reach us via email at [email protected].