OMB Control No: 0970-0455
Expiration date: 06/30/2018
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.
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.
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
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_________________________
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__________________________
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_____________________
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______________________
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.
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________________________
Voluntary - With which of the following ethnic classifications do you identify yourself?
Hispanic/Latino
Not Hispanic/Latino
Prefer not to answer
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
Voluntary - With which of the following do you identify yourself?
Male
Female
Prefer not to answer
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Windows User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |