Form RCI Form RCI Form RCI Form

OMB No. 0930-0255

Expiration Date: xx/xx/xx

Reviewer Contact Information

SAMHSA, Division of Grant Review

5600 Fishers Lane

Rockville, Maryland

USA

20857

Date:

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Contact Phone:

Alternate Phone:

Contact Email:

Past or Current Affiliation: Gender:

Community Based Organization Consultant

Direct Treatment for Mental Health or SUD

Faith Based Organization

Federal, State, and County Government SUD Prevention

Tribal Government Research

University, Colleges, and Other Higher Education Systems Other:

Male

Female Transgender

None of These

Education:

Associates’ Degree

Bachelor’s Degree Master’s Degree Ph.D

M.D.

Other:

Degree Concentration:

License (Enter type of license):

Professional License in Mental Health or

Substance Use Disorders:

License #:

License State:

License Expiration Date:

Ethnicity:

Hispanic or Latino?

Yes

No

Race: (Mark all that apply):

African American

Alaska Native/American Indian

Tribal Affiliation:

Asian

White

Native Hawaiian/Pacific Islander

Primary Expertise:

Drug-Free Communities Reviewer SUD Prevention

SUD Treatment

Mental Health

Secondary Expertise (Choose a maximum of 5 boxes from Sections A through C):

1. Target Population:

Adolescents/High-Risk Youth

Consumer/Consumer Supporter

Family Member of Consumer

Disabled

Families

Homeless

Infants and Children

LGBTQ

Military and Veterans

Minorities (African American,

Hispanic or Latino, etc.)

Seriously Mentally Ill Adults

Tribes or Tribal Organizations

Women

Other:

2. SUD and Clinical Issues:

Alcohol

Antisocial Behavior

Crack/Cocaine

Children's Mental Health

Co-Occurring SUD and Mental Health

Eating Disorders

Emergency Treatment

Heroin

HIV/AIDS

Inhalants

Marijuana

Medical Treatment

Medication Assisted Treatment

Methamphetamine

Methadone Treatment

Opioid Use Disorders

Post-traumatic Stress

Prescription Drugs

Psychotic Disorders

Suicide Prevention

3. Other Expertise:

Counseling

Criminal Justice Programs

Behavioral Health

Workplace Programs

Coalition Building/Collaboration

Health Information Technology

Program Planning Management

Recovery Support Services

Research/Evaluation

Residency Training (Medical)

Rural Communities

Training/Technical Assistance

State Systems

Integrated Care

Other:

Grant Review Experience

Provide specific information about your review history in the checkbox(es) below:

Experienced SAMHSA Grant Reviewer

Reviewer Training Completed, Date:

No SAMHSA Grant Review Experience

Reviewer Training Completed if applicable, Date:

Experienced Federal Grant Reviewer

Experienced Non-Federal Grant Reviewer

Include a brief paragraph summarizing your general expertise in relation to prevention and/or treatment of mental and substance use disorders.

Burden Statement: This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) in the planning of the SAMHSA Peer Grant Reviewers Program. This voluntary information collected will be used at an aggregate level to determine the reach, consistency, and quality of the Program. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0255. Public reporting burden for this collection of information is estimated to average 1.5 hours per encounter, 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, 5600 Fishers Ln, Room 15E57B, Rockville, MD 20857.

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