Form UnNumbered Demographic Information on Applicant

Form - DEMOGRAPHIC INFORMATION ON APPLICANTS

Vacancy Announcement No.:

Position Title and Grade:

Name (Last, First, Middle Initial):

Your Privacy Is Protected

This information is used to determine if our recruitment efforts are reaching all segments of the population, consistent with Federal equal employment opportunity laws. Your voluntary responses are treated in a highly confidential manner. Your responses are not released to the panel rating the applications, to the selecting official, to anyone else who can affect your application, or to the public. No information taken from this form is ever placed in your Personnel file. This is vital information not available from any other source. We can only get it directly from you. Thank you for helping us to provide better service.

1. How did you learn about this position? (Check One):

1. Agency Internet Site recruitment. 13. Agency or other Federal government on campus.

2. Private Employment Web Site. 14. Religious organization.

3. Other Internet Site. 15. School or college counselor or other official.

4. Poster. 16. Job Fair (give location:___________________).

5. Newspaper. 17. Friend or relative working for this agency.

6. Magazine. 18. State Vocational Rehabilitation Agency.

7. TV/Radio. 19. Professional organization or publication.

8. Student association. 20. Other.

9. Private Employment Office.

10. State Employment Office.

11. Federal, state, or local Job Information Center.

12. Agency Human Resources Department (bulletin board or other announcement).

2. Sex (Check One):

1. Male 2. Female

3. Ethnicity (Check One):

1. Hispanic or Latino—a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

2. Not Hispanic or Latino.

4. Race (Check all that apply):

1. American Indian or Alaska Native—a person having origins in any of the original peoples of North or South America (including Central America), and who maintains tribal affiliation or community attachment.

2. Asian—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, or Vietnam.

3. Black or African American—a person having origins in any of the black racial groups of Africa.

4. Native Hawaiian or Other Pacific Islander—a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.

5. White—a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Privacy Act and Paperwork Reduction Act Statement

Privacy Act Information: This information is provided pursuant to Public Law 93-579 (“Privacy Act of 1974"), for individuals completing Federal records and forms that solicit personal information. The authority is Title 5 of the U.S. Code, sections 1302, 3301, 3304, and 7201. Purpose and Routine Uses: No individual data is ever provided to selecting officials. This form will only be seen by HR Personnel and Equal Employment Opportunity officials. Data summarizing all applicants for a position will be used to determine if we are effectively recruiting from all segments of the population, in conformance with the requirements of Federal equal employment opportunity laws. Only summary data is reported, and only in a format which can not be broken out by individual applicants. Effects of Nondisclosure: Providing this information is voluntary. No individual personnel selections are made based on this information.

Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq,) requires us to inform you that this information is being collected for planning and assessing affirmative employment program initiatives. Response to this request is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The estimated burden of completing this form is three (3) minutes, including the time for reviewing instructions. Direct comments regarding the burden estimate or any other aspect of this form to the Equal Employment Opportunity Commission, Affirmative Employment Division, Federal Sector Programs, 1801 L St., NW, Washington, DC 20507 and to the Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.

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