Form RCI Form RCI Form RCI Form

OMB No. 0930-0255
Expiration Date: 10/31/2022

SAMHSA, Division of Grant Review
5600 Fishers Lane
Rockville, Maryland
USA
20857

Reviewer Contact Information
Date:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Contact Phone:
Alternate Phone:
Contact Email:

Past or Current Affiliation:

Education:

Gender:

Community Based Organization

Male

High School

Consultant

Female

Certificate

Direct Treatment for Mental Health or SUD

Transgender

Associates’ Degree

Faith Based Organization

Prefer not to Answer

Bachelor’s Degree

Federal, State, and County Government

Master’s Degree

SUD Prevention

Ph.D

Tribal Government

M.D.

Other:

Research

Degree Concentration:

Federally Qualified Health Centers
Technical Training Centers
Certified Community Behavioral Health Clinics

Ethnicity:

University, Colleges, and Other Higher Education Systems

Hispanic or Latino?
Yes

Other:

No

Race: (Mark all that Apply)
African American
American Indian/Alaskan Native
Tribal Affiliation:
Asian
White
Native Hawaiian/Pacific Islander
Mixed Race

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Primary Expertise:
Drug-Free Communities Reviewer
SUD Prevention
SUD Treatment
Mental Health

License (Enter type of License):
Professional License in Mental Health or
Substance Use Disorders:
License #:
License State::
License Expiration Date:
No License

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

B. SUD and Clinical Issues:

C. Other Expertise:

Adolescents/High-Risk Youth

Alcohol

Counseling

Consumer/Consumer Supporter

Antisocial Behavior

Criminal Justice Programs Behavioral

Family Member of Consumer
Disabled
Families

Crack/Cocaine
Children's Mental Health
Co-Occurring SUD and
Mental Health

Health
Workplace Programs Coalition
Building/Collaboration Health

Homeless

Eating Disorders

Information Technology Program

Infants and Children

Emergency Treatment

Planning Management Recovery

LGBTQ

Heroin

Support Services Research/

HIV/AIDS

Evaluation Residency Training

Military and Veterans
Minorities (African American,
Hispanic or Latino, etc.)
Seriously Mentally Ill Adults
Tribes or Tribal Organizations

Inhalants

(Medical) Rural Communities

Marijuana
Medical Treatment Medication
Assisted Treatment

Training/Technical Assistance
State Systems

Methamphetamine

Integrated Care

Tribal Health System

Methadone Treatment

Peer Experience/Lived Experience

Women

Opioid Use Disorders

Other:

Other:

Post-Traumatic Stress
Prescription Drugs
Psychotic Disorders
Suicide Prevention
Screening/Prevention/
Emergency Preparedness

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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
Junior Reviewers
Community Reviewers

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

RESET FORM

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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.
SAMHSA Values That Promote Positive Behavioral Health
SAMHSA expects applicants to use grant funds to implement high quality programs, practices, and policies that are recoveryoriented, trauma-informed, and equity-based as a means of improving behavioral health.
Recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and
strive to reach their full potential.” Recovery oriented systems of care promote partnering with people in recovery from
mental and substance use disorders and their family members to guide the behavioral health system and promote individual,
program, and system-level approaches that foster: Health—managing one’s illnesses or symptoms and making informed
healthy choices that support physical and emotional wellbeing; Home—a stable and safe place to live; Purpose—meaningful
daily activities such as a job or school; and Community—supportive relationships with families, friends and peers.
Trauma-informed care recognizes and intentionally responds to the lasting adverse effects of experiencing traumatic events
(e.g., domestic violence, war, sexual abuse, generational trauma, etc.). Principles of recovery and trauma-informed care
include: Hope–emphasizing that change, growth and healing are real and possible; Person-Driven-optimizing autonomy and
independence; Many Pathways–adopting individualized approaches; Respect–treating all with dignity and respect and
protecting rights; Safety-assuring all are physically and psychologically safe; Trustworthiness and Transparency–conducting
transparent operations and decisions to build trust; Collaboration and Mutuality- leveling power differences to facilitate
healing relationships; and Cultural, Historical, & Gender Issues–actively moving beyond stereotypes/biases while offering
culture and gender-responsive services including traditional cultural practices and addressing historical trauma. A key element
of recovery and trauma-informed care is the full inclusion of people with lived experience and their family members in the
design, delivery, and evaluation of behavioral health services and policies.
Behavioral health equity is the right to access high quality and affordable health care services and supports for all populations
regardless of the individual’s race, age, ethnicity, gender, disability, socioeconomic status, sexual orientation, or geographical
location. Advancing behavioral health equity involves ensuring that everyone has a fair and just opportunity to be as healthy as
possible. In conjunction with quality services, this involves addressing social determinants of health, such as employment and
housing stability, insurance status, proximity to services, and culturally responsive care – all of which have an impact on
behavioral health outcomes.

1“Behavioral health” means the promotion of mental health, resilience and wellbeing; the treatment of mental and substance
use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families
and communities.

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