OMB NO: 1820-0583 

Expiration 08/31/2014

Office	of	Special	Education and	Rehabilitative	Services	

Peer	Reviewer	Data	Form

1

Thank you for your interest in being a peer reviewer for the Department of Education, 

Office of Special Education and Rehabilitative Services (OSERS). By responding to the 

following questions you can assist us in making appropriate selections for equitable peer 

review panels. Send the completed form and current resume to OSERS Peer Reviewer 

email address at: OSERSPRS@ed.gov. We appreciate your time in completing this form.

First Submission

Update to Previous Submission

(Complete section 1 plus any section needing updates)

1. Mr. Mrs. Ms.

First Name

Middle Initial

Last Name 

Suffix (i.e. Jr., III) 

2. Gender: Male Female

3. Home Address:

P.O. Box

Street

City, State & Zip Code 

Phone Number 

TDD Number 

Fax Number 

E-mail Address 

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond 

to a collection of information unless such collection displays a valid OMB control 

number. Public reporting burden for this collection of information is estimated to 

average 15 minutes per response, including time for reviewing instructions, searching 

existing data sources, gathering and maintaining the data needed, and completing and 

reviewing the collection of information. The obligation to respond to this collection is 

voluntary. Send comments regarding the burden estimate or any other aspect of this 

collection of information, including suggestions for reducing this burden, to the U.S. 

Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email 

ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0583. Note: Please 

do not return the completed OSERS Peer Reviewer Data Form to this address.
OMB NO: 1820-0583 

Expiration 08/31/2014

Office	of	Special	Education and	Rehabilitative	Services	

Peer	Reviewer	Data	Form

2

4. Work/Alternate Address:

Employer 

Department 

Position Title 

P.O. Box

Street

City, State & Zip Code 

Phone Number 

TDD Number 

Fax Number 

 E-mail Address 

5. List Educational Degrees and Areas of Expertise, including any experience 

reviewing Federal discretionary grant applications:

Please check one address (home or work/alternate) for each type of correspondence.

Financial 

Address

Address where financial documents (e.g., 1099’s, honorarium and 

per diem checks) will be sent. 

Home 

Work/Alt.

FedEx 

Address

Address where confirmation packets, applications, and airline 

tickets will be sent. Must include a street (i.e., cannot be a P.O. Box).

Home 

Work/Alt.

Roster 

Address

Address that will appear on the panel roster for dissemination to 

other peer reviewers.

Home 

Work/Alt.

6. Ethnicity: Are you (select only one)

Hispanic or Latino

Not Hispanic or Latino

Race: Are you (select one or more)

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Asian

Black or African American 

White

7. Disability: Please select any that apply:

Individual with a Disability

Spouse/Partner of an Individual with a Disability

Parent of an Individual with a Disability

 Birth date of your youngest Child with a Disability

Sibling of an Individual with a Disability

Any reasonable accommodation required by reviewers will be provided.