Children's Bureau Grant Reviewer Recruitment Module

Children’s Bureau Discretionary Grant Reviewer Recruitment Questionnaire

Please complete the following information in order to help us select peer reviewers. The first six questions are mandatory to complete your grant reviewer application.

1. What is your occupation? (check all that apply)

__ Social Worker or Child Welfare

__ Social Work Education

__ Social Work or Child Welfare Administration

__ Evaluator or Researcher

__ Retired

Other_______________________

1a. For how many years have you been in this position?

__ 0-3 Years

__ 4-6 Years

__ 7-10 Years

__ More than 10 Years

2. What is your highest degree completed?

__ Doctorate in Social Work

__ Doctorate in Other Area

__ Masters in Social Work

__ Masters in Other Area

__ Bachelors in Social Work

__ Bachelors in Other Area

__ Associates

Other_________________________

3. What is your current or most recent work setting?

__ Child welfare state, county, or local agency

__ Foster care agency

__ Child abuse prevention agency

__ Adoption agency

__ University or other research/evaluation position

__ University or other social service evaluator

Other__________________________

4. Are you currently a Federal Employee?

__ Yes

__ No

4a. If “Yes” Please select your Agency

__ Administration for Children and Families (ACF)

__ Administration for Community Living (ACL)

__ Agency for Healthcare Research and Quality (AHRQ)

__Agency for Toxic Substances and Disease Registry (ATSDR)

__ Centers for Disease Control and Prevention (CDC)

__ Centers for Medicare & Medicaid Services (CMS)

__ Food and Drug Administration (FDA

__ Health Resources and Services Administration (HRSA)

__ Indian Health Service (IHS)

__ National Institutes of Health (NIH)

__ Office of Minority Health (OMH)

__ Office of the Assistant Secretary for Health (OASH)

__ Office of the Assistant Secretary for Planning and Evaluation (ASPE)

__ Office of the Assistant Secretary for Preparedness and Response (ASPR)

__ Office of the National Coordinator for Health Information Technology (ONC)

__ Substance Abuse and Mental Health Services Administration (SAMHSA)

__ United States Public Health Service (USPHS)

__ US Department of Housing and Urban Development (HUD)

__ US Department of Education (ED)

Other_____________________

5. Reviewing Experience: (Check all that apply)

__ I have reviewed for the Children’s Bureau

__ I have reviewed for other parts of the Administration for Children and Families

__ I have reviewed for other federal agencies

__ I have reviewed for a non-federal organization/government

__ I have no reviewing experience

Other______________________

6. Have you worked for an organization that has been a recipient of a Children’s Bureau discretionary grant?

__ Yes

__ No

__ Don’t Know

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 8 and 9 -- 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.

Currently, the following information will not be used in the selection of grant reviewers for Children’s Bureau discretionary grant programs. Rather, at this time the information will be used solely to monitor the diversity of our grant reviewer pool.

7. Voluntary - Are you or have you been: (Check all that apply)

__ An adult who was formerly in foster care or adopted from foster care

__ A parent whose child was in foster care

__ Affiliated with an Asian American/Native American Pacific Islander-Serving Institution

(AANAPISI)

__ Affiliated with any other Asian-serving institution

__ Affiliated with any other Native Hawaiian or other Pacific Islander-serving institution

__ A current or former faculty member at an AANAPSI

__ Affiliated with a Historically Black College or University (HBCU)

__ A current or former faculty member at an HBCU

__ Affiliated with any other Black or African American-serving institution

__ Affiliated with an Hispanic-Serving Institution (HSI)

__ A current or former faculty member of an HSI

__ Affiliated with a Native American Tribe or Urban Indian Organization

__ Affiliated with any other American Indian or Alaskan Native-serving institution

__ Affiliated with the Lesbian, Gay, Bisexual or Transgender Community

__ A military veteran

__ Prefer not to answer

Comments________________________

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

__ Hispanic/Latino

__ Not Hispanic/Latino

__ Prefer not to answer

9. 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

10. Voluntary – Gender Identity:

__ Female

__ Male

__ Trans (MTF)

__ Trans (FTM)

__ Genderqueer

__ Other: __________

__ Decline to answer

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to register discretionary grant review candidates from which to recruit grant reviewers. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0477 and the expiration date is 06/30/2023. If you have any comments on this collection of information, please contact Jan Rothstein at jan.rothstein@acf.hhs.gov.