ORR Grant Reviewers Electronic Recruitment Form (Previously approved, ongoing collection)

OMB Control Number: 0970-0477
Expiration Date: 6/30/2018

Grant Reviewer Electronic Recruitment Form

Public reporting burden of this collection of information is estimated to
average one hours 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.

Reviewer Electronic Registration Script

Mandatory Information
Title
Brother
Dr.
Hon.
Min.
Miss
Mr.
Mrs.
Ms.
Pastor
Rev.
Rev. Dr.
First Name
Last Name
Address City
State
Alabama AL
Alaska AK
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Florida FL
Georgia GA
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas KS
Kentucky KY
Louisiana LA
Maine ME
Maryland MD
Massachusetts MA
Michigan MI

(CST)
(AKST)
(MST)
(CST)
(PST)
(MST)
(EST)
(EST)
(EST)
(EST)
(EST)
(MST)
(CST)
(EST)
(CST)
(CST)
(CST)
(CST)
(EST)
(EST)
(EST)
(EST)

4
10
9
6
9
8
1
3
3
4
4
10
5
5
7
7
4
6
1
3
1
5

Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
New Mexico NM
New York NY
North Carolina NC
North Dakota ND
Ohio OH
Oklahoma OK
Oregon OR
Pennsylvania PA
Rhode Island RI
South Carolina SC
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
Wyoming WY
American Samoa AS
Federated States of
Micronesia FM
Guam GU
Hawaii HI
Marshall Islands MH
Northern Mariana
Islands MP
Puerto Rico PR
Virgin Islands, U.S. VI
Armed Forces the
Americas AA
Armed Forces Europe
AE
Armed Forces Pacific AP
United Kingdom UK
Zip
Cell Phone Number Home
phone Number Work Phone
Number Email Address

(CST)
(CST)
(CST)
(MST)
(CST)
(PST)
(EST)
(EST)
(MST)
(EST)
(EST)
(CST)
(EST)
(CST)
(PST)
(EST)
(EST)
(EST)

5
4
7
8
7
9
1
2
6
2
4
8
5
6
10
3
1
4
8
4
6
8
1
3
10
3
5
8
9

9
9
9
2
2

Are you a current Federal Employee? Yes No
Are you a current Federal Contractor? Yes No
Education/ Experience:
Highest Degree Earned/ Discipline
High School Diploma
Undergraduate Degree
Graduate Degree
Post Graduate Degree
Do you have previous experience as a grant reviewer? Yes No
Do you have previous experience as a panel lead? (e.g. Chairperson, Team Lead, Facilitator) Yes No
When did you last participate in a grant review?
Never
Within the last 1-3 years
Within the last 4-6 years
Within the last 7-10 years
More than 10 years ago
Reviewer-selected Expertise Designation
 Abstinence Education
 Adolescent Health
 Affordable Housing Finance
 Asset Building
 At-Risk Youth
 Banking/Finance
 Business Expansion
 Capacity-Building
 Child Care
 Child Services
 Clinical Services
 Collaboration Among Nonprofits
 Communities
 Community Development
 Community Facilities
 Consumer Finance
 Credit Unions
 Crisis Intervention / Transitional Housing
 Cultural Diversity
 Economic Development
 Education
 Employment Services
 Fair Housing
 Faith-Based & Community Org Mgt / Ldrshp
 Families & Low Income Individuals
 Family / Domestic Violence
 Financial Education / Literacy
 Financial Services
 General Business for Non Profit
 Health
 Healthy Food Financing
 Higher Education
 Homeownership
 Human Trafficking
 Information Management / Data Analysis
 Intermediary Lending
 Legal Profession/Legal Services
 Mental Health Services
 Micro-Enterprise / Self-Employment
 Microfinance/Microlending
 Monitoring/Evaluation

 Mortgage/Lending
 Native Americans
 New Business Development
 Nonprofit Management
 Personal Experience as Refugee/Asylee
 Process Monitoring and Control
 Quality Improvement/Control
 Refugee/Asylee Services
 Refugees
 Research / Evaluation
 Revenue Dev't Strategies / Fundraising
 Rural Development
 Small Business / Entrepreneurship
 Social Services
 Social Work
 Systems Development and Testing
 Systems Integration
 Tax Assistance / EITC Outreach
 Training & Technical Assistance
 Underwriting
 Youth Counseling
Resume Upload
Voluntary Information
Which of the following do you identify yourself with:
□
American Indian or Alaskan Native
□
Asian or Pacific Islander
□
Black, not of Hispanic Origin
□
Hispanic
□
White, not of Hispanic Origin