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 P eer 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.**  **M** s. 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, se arching 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. **L ist**  **E ducational**  **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 Ad**  **dress** Address where financial documents (e.g., 1099’s, honorarium and

per diem checks) will be sent

. Home Work/ Alt. **FedEx Ad**  **dress** 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 Ad**  **dress** 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 selec t any that apply : Individual with a Disability Spouse/Partner of an Individual with a Disability Parent of an Individual with a Disability B irth date of your youngest Child with a Disability Sibling of an Individual with a Disability **Any r easonable accommodation required by reviewers**  **will be provided.**