SAMHSA Call For Reviewers Application, Substance Abuse & Mental Health Services Administration

SAMHSA Immediate Call For Reviewers

SAMHSA Online Application for Peer Grant Reviewers

Form Approved
OMB No. 0930-0255
Expires: August 31, 2013

Public reporting burden for this collection of information is estimated to average 1.5 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:

SAMHSA Reports Clearance Officer
Paperwork Reduction Project (0930-0255)
1 Choke Cherry Road
Room 3-1053
Rockville, Maryland 20857

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. The OMB control number for this project is 0930-0255.

REVIEWER CONTACT INFORMATION
Prior to submitting, please read our Privacy Statement.

Name and information
Preferred FedEx Mailing Location:
Preferred Daytime Contact Number:
First Name:
Last Name:
Home Street Address:
Home Street Address 2:
Home City:
Home State:
Home Zip code:
Home Phone:
Home Fax:
Home Email:
NOTE: You must supply a valid email address for either your Home email account or Work email (space provided below) or we may not be able to contact you.
Organization/Company:
Title (if applicable):
Work Street Address:
Work Street Address 2:
Work City:
Work State:
Work Zip code:
Work Phone:
Work Fax:
Work Email:
Additional Contact # (Cell Phone):
Contact Preferences
Preferred Contact Method:
Preferred Contact Location:
REVIEWER INFORMATION AND EXPERTISE
Ethnicity:
Race: Please select one or more
Gender:
Education Level:
Professional Affiliation:
Other Affiliation: (please specify only if not found above)
Consumer:
General Expertise. Please select the one area that best describes your general expertise.
Expertise. Please choose no more than 4 areas that describe your specific level of expertise. TIP! To select multiple entries, press the [CTRL] key on your keyboard while selecting a menu item with your mouse.	* Consumer supporter (provide support in a nonprofessional capacity)
Other Expertise: (please specify only if not found above)
Grant Reviewing Experience	I am a/an:
Please describe your experience in grant reviewing, listed from most recent to least recent. Please include dates, location, ageny and topic:
REMINDER!
Remember to also send us your resume Email Resume to: reviewer@samhsa.hhs.gov Regular Mail to: SAMHSA REVIEWER OPPORTUNITIES Office of Review 1 Choke Cherry Road Room 3-1053 Rockville, MD 20857 NOTE: This form does not email your resume. You must do that separately, after you've finished filling out this form. If you are finished, please click the SEND button below to submit yourapplication. Thank you.

Last updated: 04/28/2011

State Systems
Research / Evalulation
Criminal Justice
Faith-based & Community Approaches
Program Planning & Management
HIV/AIDS
Adolescents
Alcohol
Fetal Alcohol Sydrome
Crack / Cocaine
Ecstasy
Heroin
Marijuana
Methadone Treatment
Methamphetamine
OxyContin
Co-occurring Substance Abuse & Mental Health
Children's Mental Health
Traumatic Stress
Seriously Mental Ill Adults
Violence
Coalition Building / Colaboration
Families
Homelessness
Residency Training (Medical)
Suicide Prevention
Veterans Substance Abuse/Mental Health Issues
Veterans Family Members
Consumer (have experienced treatment and recovery)
Consumer supporter*
Consumer AND consumer supporter
Other

Substance Abuse & Mental Health Services Administration

SAMHSA Immediate Call For Reviewers

SAMHSA Online Application for Peer Grant Reviewers

REVIEWER CONTACT INFORMATION

Name and information

Contact Preferences

REVIEWER INFORMATION AND EXPERTISE

REMINDER!