Revisions to DODEA Form 5012

REVISIONS TO DODEA FORM 5012

DoDEA Form 5012 has been revised as follows:

Section 1 (Part after title) Remove, and add, "RETURN COMPLETED FORM TO:

Department of Defense Dependents Schools Human Resources Center 4040 North

Fairfax Drive, Arlington, VA 22203-1634"

________________________________________________________________________

New Section, add, "Name (Last, First, Middle) Social Security Number, Birth

Date (YYYYMMDD)"

________________________________________________________________________

Section 2 - General Information, Remove, and add new revision, "The

information collected from this questionnaire is used to help insure that

the Department of Defense Dependents Schools (DoDDS) personnel practices

meet the requirements of Federal law. Your responses are voluntary

(underline sentence). This information is used as necessary to plan for

equal employment opportunity throughout the Federal government. It is also

used by the U.S. Office of Personnel Management or employing agency

maintaining the records to locate individuals for personnel research or

survey response and in the production of summary descriptive statistics and

analytical studies in support of the function for which the records are

collected and maintained, or for related workforce studies.

________________________________________________________________________

Add, "Privacy Act Statement

AUTHORITY (bold): 42 U.S.C. Section 2000e-16; Office of Management and

Budget 1997 Revisions to the Standards for the Classification of Federal

Data on Race and Ethnicity; 20 U.S.C. 902, 903, and E.O. 9397.

PRINCIPAL PURPOSE (bold): This information is used as necessary to plan for

equal employment opportunity throughout the Federal government. It is also

used by the U. S. Office of Personnel Management or employing agency

maintaining the records to locate individuals for personnel research or

survey response and in the production of summary descriptive statistics and

analytical studies in support of the function for which the records are

collected and maintained, or for related workforce studies.

ROUTINE USES (bold): Release of ethnicity data is authorized within the

Department of Defense upon a demonstrated need to know basis when release is

consistent with the purposes for which the data was collected. Release of

ethnicity data is authorized to agencies outside the DoD by DoD and

Government-wide Systems Notices, which may be found at

http://www.defenselink.mil/privacy/notices/osd.

DISCLOSURE (bold): Your disclosure of the information requested on this

form is voluntary. Failure to provide, or delay in providing, the requested

information has no impact on your employment status, but in the instance of

missing information, other agency sources may be used to obtain it.

________________________________________________________________________

Number 1. (Questionnaire) remove all, add new revision, "

RACE, ETHNICITY, AND SEX (bold). (Please identify yourself in terms of the

race, ethnicity, and sex categories below:)

CATEGORIES AND DEFINITIONS (bold) RACE (bold):

1 - American Indian or Alaska Native (bold). A person having origins in any

of the original peoples of North and South America (including Central

America), and who maintains tribal affiliation or community attachment.

2 - Asian (bold). A person having origins in any of the original peoples of

the Far East, Southeast Asia, or the Indian subcontinent including for

example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the

Philippine Islands, Thailand, and Vietnam.

3 - Black or African American (bold). A person having origins in any of the

black racial groups of Africa.

4 - Native Hawaiian or other Pacific Islander (bold). A person having

origins in any of the original peoples of Hawaii, Guam, Samoa, or other

Pacific Islands.

5 - White (bold). A person having origins in any of the original peoples of

Europe, the Middle East, or North Africa.

ETHNICITY (bold):

1 - Hispanic or Latino (bold). A person of Cuban, Mexican, Puerto Rican,

South or Central American, or other Spanish culture or origin, regardless of

race.

________________________________________________________________________

Add new section

a. RACE (bold) (Check all that apply)

1 - American Indian or Alaska Native

2 - Asian

3 - Black or African American

4 - Native Hawaiian or Other Pacific Islander

5 - White

6 - Other

b. ETHNICITY (bold)

Are you Hispanic or Latino?

1- YES

2 - NO

c. SEX (bold)

M - Male

F - Female

________________________________________________________________________

Number 2 - Remove all

________________________________________________________________________

Number 3 - REPORTABLE DISABILITY (bold), Remove all and add new revision, "

A physical or mental disability is NOT determined by a person's ability to

perform his or her work but by a disability, or a history of such

disability, which is likely to cause the employee to experience difficulty

in obtaining, maintaining or advancing in employment. This does not apply

solely to an employee's current position, but applies to the total career

life cycle of that employee.

(In the case of multiple disabilities, choose the code which describes the

impairment that would most likely result in such difficulties.)

Do you have a physical disability? (bold)

1 - YES

2 - NO

________________________________________________________________________

ADD new section, "HOW DID YOU LEARN ABOUT THE DoDDS EMPLOYMENT

OPPORTUNITIES? (bold)(Check all that apply)

001 - Friend or Relative Working for DoDDS

002 - Friend or Relative not Working for DoDDS

003 - On-Campus Recruitment by DoDDS

004 - Direct Mailing by DoDDS

005 - Government Job Information Center

006 - State Employment Office

007 - Private Information Office

008 - State Rehabilitation Center

009 - Veterans Association/Employment Office

10 - School Placement Officer

0A - Print Advertisement - Name of Publication:

0B - On-line Information - Name of Site:

0C - Professional Conventions/Meeting - Name of Event:

0C - Other (please specify):