Eligibility Information From Applicants: Reviewer Information Form for General Reviewer and for Specific Reviewers (Previously approved, ongoing collection)

OMB Control Number: 0970-0477

Expiration Date: 3/31/2019 Information Collection for Specific Reviews

Review Title(s):___[To be completed by contractor]__________________________________________

Dates of Review(s): ):___[To be completed by contractor]______________________________________

Please fill out the table below:

Name:      

Address During Review Dates:      

Time Zone During Review Dates:      

Home Phone:      

Office Phone:      

Cell Phone:      

Preferred Email [please add “CONTRACTOR EMAIL”] to your approved list of addresses to prevent it going to spam):      

3-5 Areas of Expertise*: (see attached list)      

Race/Ethnicity (voluntary; see below for more information): PLEASE RESPOND BELOW

Availability On All Review Dates: All days No, please explain:      

*Please also attach your latest resume or curricula vitae

VOLUNTARY QUESTIONS: Diversity of Membership of Peer Review Panels

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 indicating your race and/or ethnic heritage by checking the appropriate box for questions 1 thru 3. Please note that these questions utilize 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 information will not be used in the selection of grant reviewers for Office of Planning, Research and Evaluation discretionary grant programs. The information will be used solely to monitor the diversity of our grant reviewer pool.

1. Voluntary - With which of the following racial classifications do you identify yourself? (Check all that apply)

__White

__Black or African American

__Asian

__Native Hawaiian or Pacific Islander

__American Indian or Alaskan Native

__Prefer not to answer

2. Voluntary - With which of the following ethnic classifications do you identify yourself?

­­__Hispanic/Latino

__Not Hispanic/Latino

__Prefer not to answer

Expertise Sheet 1: Early Childhood

Please check all areas of expertise.

	1. research methods		17. dual language learners/esl		33. cultural responsiveness
	2. evaluation research/methods		18. special needs/developmental delays		34. other______________
	3. implementation research		19. low income families		35. other______________
	4. statistics/secondary analyses		20. American Indian/Alaskan native		36. other______________
	5. assessment/measurement development		21. Migrants/Seasonal farmworker families		37. other______________
	6. early education		22. parenting/parent-child interactions
	7. child care		23.family engagement
	8. child welfare		24. child behavior management
	9. home visiting		25. social and emotional development/emotion regulation
	10.Pre-k		26. school readiness
	11. child care subsidies		27. health/nutrition/physical development
	12. Head Start		28. language development
	13. infants/toddler		29. literacy
	14. preschool		30. math
	15. homeless		31. program quality
	16. foster care		32. professional development and training

Expertise Sheet 2: Welfare and Family Self-Sufficiency

Please check all areas of expertise.

	1. research methods		15. two-generation programs		29. impacts of resource scarcity
	2. evaluation research/methods		16. job search services		30. executive functioning
	3. implementation research		17. employment and the labor market		31. goal-setting and self-regulation
	4. statistics/secondary analyses		18. workforce development		32. coaching interventions
	5. assessment/measurement development		19. subsidized and transitional employment		33. case management
	6. low-income families and children		20. career pathways		34. program quality
	7. homeless families and homelessness		32. WIOA coordination		35. disparities in human services
	8. American Indian/Alaskan native populations		33. education and training		36. cultural responsiveness
	9. Migrants/Seasonal farmworker families		23. financial literacy		37. other______________
	10. poverty and income inequality		24. asset development		38. other______________
	11. family self-sufficiency and stability		25. behavioral economics		39. other______________
	12. social mobility		26. behavioral insights and applied behavioral sciences		40. other______________
	13. Temporary Assistance for Needy Families		27. behavioral interventions
	14. public assistance benefits and the safety net		28. psychology or neuroscience

Expertise Sheet 3: Family Strengthening

Please check all areas of expertise.

	1. research methods
	2. evaluation research/methods
	3. implementation research
	4. statistics/secondary analyses
	5. assessment/measurement development
	6. low-income families and children
	7. marriage
	8. marital conflict
	9. relationship
	10. other______________
	11. other______________
	12. other______________
	13. other______________

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.