1 

OMB No. 0930-0255 

Expiration Date: 09/30/2025

Reviewer Contact Information SAMHSA, Division of Grant Review

5600 Fishers Lane

Rockville, Maryland

USA D 20857 ate:

First Name: 

Last Name: 

Address: 

City: 

State: 

Zip Code: 

Contact Phone: 

Alternate Phone:

Contact Email:

Past or Current Affiliation: Gender: 

Ethnicity:

Male

Hispanic or Latino?

Female

Yes

Transgender

 No

Prefer not to Answer

Community Based Organization

Consultant 

Direct Treatment for Mental Health or SUD 

Faith Based Organization 

Federal, State, and County Government

SUD Prevention 

Tribal Government

Research

Federally Qualified Health Centers

Technical Training Centers

Certified Community Behavioral Health Clinics

University, Colleges, andOther Higher Education Systems

Other: 

Education: 

Race: (Mark all that Apply)

African American 

American Indian/Alaskan Native

Tribal Affiliation:

Asian

White

Native Hawaiian/Pacific Islander

Mixed Race

High School

Certificate

Associates’ Degree 

Bachelor’s Degree 

Master’s Degree

Ph.D 

M.D.

Degree Concentration: 

Other:
2 

Primary Expertise:

Drug-Free Communities Reviewer 

SUD Prevention

SUD Treatment 

Mental Health

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

A. Target Population:

Adolescents/High-Risk Youth

Consumer/Consumer Supporter

Family Member of Consumer

Disabled

Families

Homeless

Infants and Children

LGBTQ

Military and Veterans

Minorities (African American,

Hispanic or Latino, etc.)

Seriously Mentally Ill Adults

Tribes or Tribal Organizations

Tribal Health System

Women

Other:

B. SUD and Clinical Issues:

Alcohol

Antisocial Behavior

Children's Mental Health

Co-Occurring SUD and 

Mental Health 

Eating Disorders 

Emergency Treatment 

Heroin 

HIV/AIDS 

Inhalants 

Marijuana 

Medical Treatment Medication 

Assisted Treatment 

Methamphetamine

Methadone Treatment 

Opioid Use Disorders 

Post-Traumatic Stress

Prescription Drugs 

Psychotic Disorders

Suicide Prevention

Screening/Prevention/

Emergency Preparedness

C. Other Expertise:

Counseling

Criminal Justice Programs

Behavioral Health 

Workplace Programs 

Coalition Building/Collaboration

Health Information Technology 

Program Planning Management 

Recovery Support Services 

Research/Evaluation 

Residency Training (Medical) 

Rural Communities 

Training/Technical Assistance 

State Systems 

Integrated Care

Peer Experience/Lived Experience

Other: 

Crack/Cocaine

License (Enter type of License): 

Professional License in Mental Health or 

Substance Use Disorders: 

License #: 

License State:

License Expiration Date:

No License
3 

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 GrantReviewer

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. 
4 

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.