OMB NO: Expiration X/X/2021
Thank you for your interest in being a peer reviewer for the Department of Education, Office of Special and Rehabilitative Services (OSERS). Your response to the following questions can assist us in making appropriate selections to form equitable and inclusive peer review panels. Email the completed form and your current resume to [email protected]. We appreciate your time in completing this form.
Please check the applicable box:
(Complete all sections)
Update to Previous Submission
(Complete section 1 plus any other applicable section)
1. Mr. Mrs. Ms. Dr.
Suffix (i.e. Jr., III)
2. Gender: Male Female
3. Work/Alternate Address:
City, State & Zip Code
4. Home Address:
City, State & Zip Code
Please check one address (home or work/alternate) for each type of correspondence.
Address where financial documents (e.g., 1099’s, honorarium and per diem checks) can be received.
Address where confirmation packets, applications can be received, if necessary. Must include a street (i.e., cannot be a P.O. Box).
5. Email Address:
Preferred Email Address
Alternate Email Address
6. List Educational Degrees with Major, Specialization, Licensure, Certification and Program:
7. List areas of Expertise:
If applicable, list the grant program and date of the last competition on which you served as a reviewer:
8. Hispanic Ethnicity: Are you of (select only one):
Hispanic, Latino, or Spanish origin
Not Hispanic, Latino, or Spanish origin
9. Race: Please select your race (select one or more):
American Indian or Alaska Native
Black or African American
Native Hawaiian or other Pacific Islander
10. 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
Birthdate of youngest Child with a Disability
Sibling of an Individual with a Disability
11. If you are an individual with a disability, what specific accommodations should we provide to enable your full participation in panel reviews?
12. Please list anything not covered above that may impact your availability when participating in panel reviews (i.e. work schedule)?
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. The valid OMB control number for this information collection is 1820-0583 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 mandatory (IDEA, H.R. 1350, Section 682 & EDGAR §75.217)/required to obtain or retain benefit (IDEA, H.R. 1350, Section 682 & EDGAR §75.217) or voluntary. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact U.S. Department of Education, Office of Special Education and Rehabilitative Services, Attn: Justin Hampton 550 12th St, S.W., Washington, D.C. 20202-2550
|Author||Melanie J. Winston|