Panelist Recruitment Form

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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow the public to apply to be a peer panel reviewer and allow the Administration for Native Americans (ANA) to select reviewers based on professional qualifications. Public reporting burden for this collection of information is estimated to average .4 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0477 and the expiration date is 05/31/2026. If you have any comments on this collection of information, please contact amy.zukowski@acf.hhs.gov

OMB CN: 0970-0477

                                                                                                  Exp. Date: 05/31/2026


Example: John Smith









OMB CN: 0970-0477

                                                                                                  Exp. Date: 05/31/2026



Example: John Smith




Race/Ethnic Heritage (Please check appropriate boxes)
(The Administration for Children and Families, U. S. Department of Health and Human Services is committed to increasing the diversity of the non-federal peer reviewers utilized in the competitive grants review process. In order to achieve this goal, we are requesting that you voluntarily indicate your race and/or ethnic heritage on the self-identification section by checking the appropriate boxes on the reviewer application form. Please note that this section utilizes the standard Federal identification categories. Your assistance is invaluable in enabling the agency to promote broad representation, especially for underserved and underrepresented groups and track our progress on this important goal.)







If you answered "No" to the previous question, please enter NA











OMB CN: 0970-0477

                                                                                            Exp. Date: 05/31/2026





Please read the Evaluation Criteria: Need for Assistance and the excerpt from a sample application below. In the space provided, please draft a response detailing the strengths and weaknesses of the application based on the information provided in the excerpt.


Evaluation Criteria:

Need for Assistance. To evaluate the Need for Assistance, reviewers will consider the extent to which the application includes:

     A. Concise problem statement that identifies the current condition(s) to be addressed by the project.

     B. Supporting information or data detailing the scope and nature of the problem.

     C. Current challenges standing in the way of addressing the problem.

     D. A clear description of the community to be served and who the intended beneficiaries are.


Sample Application Excerpt: The problem or issues faced by the AUIC are varied but all revolve around one theme - the AUIC has been working for years to provide services that meet the unique needs of our native community but infrastructure weaknesses, including staffing shortages, board member professional development, policy and procedure development, community outreach and the development and implementation of additional services have all been hampered by the fact that the AUIC does not have a strategic plan or an infrastructure to implement a strategic. Instead, the AUIC focus has been to pursue money where it is available and provide some services in order to keep the doors open. However, this has been done without involving the community in determining the most pressing priorities. This disconnect often times leaves the most pressing problems unresolved. The problem statement is twofold in that to truly build capacity within a small Native Urban organization you must have a multi-pronged approach to build that capacity. Because of the tough economic time faced by all Americans, especially Native Americans, and the severe lack of discretionary funds to meet these needs, any organization must address these problems in a holistic manner. We have identified two interrelated problems that have created our inability to meet our community needs.

Our Problem Statement is: (1) The staff and Board have never had the opportunity or funds to be trained in organizational management skills necessary to govern and manage a growing non-profit organization and (2) Native Americans within the Aniwer district are not utilizing the social service providers within Aniwer to meet their current needs and to assist in the process of becoming self-sufficient because of a perceived lack of cultural awareness among the social service providers. 


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