# PEER REVIEWER CHECKLIST

Thank you for your interest in being a peer reviewer for the Office of
Safe and Drug-Free Schools (OSDFS). By completing this checklist, you
can assist us in making appropriate selections for peer review panels.
Your response to the items on this checklist is optional. Please type or
print. We appreciate your time in completing this checklist.

Type Here Type Here Type Here

First Name Middle Initial Last Name

**Social Security Number:**000-00-0000

**Home Address:**

Address [Type Address Here]{.underline}

City, State & Zip Code [City]{.underline} [State]{.underline}
[00000-0000]{.underline}

Phone Number [(000) 000-0000]{.underline} Alternate Number [(000)
000-0000]{.underline}

Fax Number [(000) 000-0000]{.underline} E-mail Address [Type
Here]{.underline}

**Work Address:**

Employer Type Here

Department Type Here Position Title Type Here

Address [Type Address Here]{.underline}

City, State & Zip Code [City]{.underline} [State]{.underline}
[00000-0000]{.underline}

Phone Number [(000) 000-0000]{.underline} ext.       Alternate Number
[(000) 000-0000]{.underline}

Fax Number [(000) 000-0000]{.underline} E-mail Address [Type
Here]{.underline}

**Preferred Mailing Address:** Home Work

*(Please Note, Federal Express does not deliver to P.O. Boxes)*

Please check the box that best describes your current employment site:

School Institution of Higher Education (IHE)

School District (LEA) State or Local Government

State Education Agency (SEA) Community Organization

Other Educational Institution Private Industry

Non Profit Organization Self Employed

First responder agency (fire, EMS, police)

Other \_\_\_
(Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is your salary currently being paid in whole or in part by an
OSDFS-funded project? Yes No

If yes, please specify the funded project:

**Peer Review Experience:**

Have you served on an OSDFS peer review panel before? Yes No

If yes , when was the last year you reviewed: YYYY

Have you served on another U.S. Department of Education peer review
panel before?

Yes No

If yes, for which office did you review?

If yes, when was the last year you reviewed: [YYYY]{.underline}

Have you served as a peer reviewer for another Federal agency? Yes No

If for another agency, please specify:

If yes, when was the last year you reviewed: YYYY

**Education:** Please check the highest degree earned:

Associate Degree or Certification Doctorate

Bachelor's Degree Other (Specify) [     ]{.underline}

Master's Degree Year of Most Recent Degree: [0]{.underline}

**Ethnicity:** Are you (select only one)

Hispanic or Latino Not Hispanic or Latino

**Race:** Are you (select one or more)

Black or African American Asian White

American Indian or Alaska Native Native Hawaiian or other Pacific
Islander

**School Age Group:**

With what age groups have you had the **most** experience (**check no
more than two**):

All Ages Middle School Post Secondary

 Elementary School Secondary School

**Areas of Specialization:**

Please indicate, in rank order, up to **four (4) major areas of
specialization in education.** Of those you check, one (1) signifies the
area in which you have the highest level of experience and four (4) the
lowest.

     Alcohol Abuse Prevention      Character Education

     At-Risk Youth      Civic Education

     Civic Engagement      Constitutional

     Disaster Response      Government

     Drug Abuse Prevention      International Studies/Global Ed

     Drug Testing      Service Learning

     Emergency Management      Social and Emotional Learning

     Mentoring      Social Studies Education

     School Safety      Political Science

     School Security

     Violence Prevention

     Comprehensive, Collaborative Planning

     Evaluation

     Juvenile Justice

     Law Enforcement

     Program Management

     Mental Health

     Early Childhood Development

     Environmental Health

     Physical Activity, Physical Education

     School Counseling

     School Psychologist

     Psychiatrist

     School Health

     Social Services/Social Work

     Wellness/Fitness Training

     Alternative Education

     Curriculum Development

     Education Administration State Local

     Family Life Education

     Instruction

     Policy Development

     Project Management

     Research Program Evaluation

     Teacher Education/Quality Training

     Experience/background with diverse cultures, such as Native
Hawaiians

Other Please Specify

How did you hear about this opportunity to serve as a peer reviewer?