Form Peer Review\RCI Fo Peer Review\RCI Fo Peer Review\RCI Form

Reviewer Contact Information

SAMHSA, Division of Grant Review

5600 Fishers Lane

Rockville, Maryland

USA

20852

Date:

First Name: Last Name: Home Address: City:

State:

Zip Code:

Organization: Title:

Work Address: City:

State:

Zip Code:

Home Phone: Cell Phone: Home Email: Microsoft Email:

Work Phone: Work Email:

^{Preferred Mailing Address:} Home Work

Preferred Contact Number: _{Home Work Cell}

^{Preferred Email:} Home Work Microsoft

Past or Current Affiliation: Gender: Race/Ethnicity:

Community Based Organization Consultant

Consumer

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

Male Female Transgender

Highest Education Level:

High School

Bachelor’s Degree Master’s Degree Doctorate

African American

Alaska Native/American Indian

• Tribal Affiliation

Asian Caucasian/White Hispanic/Latino

Native Hawaiian/Pacific Islander Other

Primary Expertise:

Drug-Free Communities Reviewer Substance Abuse Prevention Substance Abuse Treatment Mental Health

Secondary Expertise (Choose a maximum of 5 boxes from Sections A through C):

1. Target Population:

Adolescents/High-Risk Youth Consumer/Consumer Supporter Disabled

Families

Infants and Children Homeless

Military Women

Seriously Mentally Ill Adults Veterans

Other

2. Substance Abuse and Clinical Issues:

Alcohol

Antisocial Behavior Crack/Cocaine Children's Mental Health Co-Occurring Substance Abuse and Mental Health

Depression/Manic Depression

Eating Disorders Ecstasy

Fetal Alcohol Syndrome

Heroin HIV/AIDS

Inhalants Marijuana

Medical Treatment Methamphetamine Methadone Treatment Obsessive Compulsive Disorder Personality Disorders

Post-traumatic Stress Prescription Drugs Psychotic Disorders Suicide Prevention

3. Other Expertise:

Counseling Drug Courts

Criminal Justice Programs

Faith Based Community Approaches

Workplace Programs

Coalition Building/Collaboration Health Information Technology Program Planning Management Research/Evaluation Residency Training (Medical) Training/Technical Assistance State Systems

Violence Prevention Programs

Integrated Care Other

Grant Review Experience - provide specific information about your review history in the box(es) below:

Experienced SAMHSA Reviewer (Dates/No. of Reviews Completed)

Experienced Federal Reviewer (Dates/Agency/No. of Reviews Completed)

Experienced Non-Federal Reviewer (Dates/Agency/No. of Reviews Completed)

No Review Experience

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