OSERS Peer Reviewer Data Form

OMB NO: Expiration X/X/2021

Office of Special Education Programs Peer Reviewer Data Form

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:

First Submission

(Complete all sections)

Update to Previous Submission

(Complete section 1 plus any other applicable section)

1. Mr. Mrs. Ms. Dr.

First Name      

Middle Initial      

Last Name      

Suffix (i.e. Jr., III)      

2. Gender: Male Female

3. Work/Alternate Address:

Employer      

Department      

Position Title      

P.O. Box      

Street      

City, State & Zip Code      

Phone Number      

TDY Number      

Fax Number      

4. Home Address:

P.O. Box      

Street      

City, State & Zip Code      

Phone Number      

Cell Number      

TDD Number      

Fax Number      

Please check one address (home or work/alternate) for each type of correspondence.

Financial Documents	Address where financial documents (e.g., 1099’s, honorarium and per diem checks) can be received.	Home Work/Alt.
Other Documents	Address where confirmation packets, applications can be received, if necessary. Must include a street (i.e., cannot be a P.O. Box).	Home Work/Alt.

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

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

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

Other:

Explain:      

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 12^th St, S.W., Washington, D.C. 20202-2550

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