FS-1700-5 Optional Ethnicity Questionnaire

US Forest Service OMB Info Collection 0596-New (Exp. xx/2010)

FS-1700-5 (Rev. 6/07)

Optional

Ethnicity Questionnaire

The Forest Service is gathering the following information to include in an annual report to Congress and we would appreciate your assistance. Response is voluntary.

1. Indicate the program you are participating in: (select one)

Hosted

Job Corps (JC)

Volunteers (Including TAP)

Youth Conservation Corps (YCC)

2. Ethnicity (select one):

Hispanic or Latino

Not Hispanic or Latino

3. Race (select all that apply):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Burden and Discrimination Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-NEW. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.