Nifa-19-01 Research & Related Personal Data Reviewer Form

RESEARCH & RELATED PERSONAL DATA

Reviewer

OMB No. 0524-0041

Expiration Date:

The Federal Government has a continuing commitment to monitor the operation of its review and award processes to identify and address any inequities based on gender, race, ethnicity, or disability. Submission of the requested information is voluntary and is not a precondition of serving on the panel. However, information not submitted will seriously undermine the statistical validity, and therefore the usefulness, of information received from others. Any individual not wishing to submit some or all the information should check the box provided for this purpose. This form will not be duplicated and will only be used for ensuring that the panel includes individuals from diverse populations. This data will be kept confidential.

*First Name:

Reviewer

Gender:

Race (check all that apply):

Asian

Black or African American

^Ethnicity: List the state and zip code your company headquarters or university is located in. If not employed, list the state and zip code you currently reside in.

*State:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond

to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information

collection is 0524-0041. The time required to complete this information collection is estimated to average .5 hour 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.