NATIONAL SCIENCE FOUNDATION APPLICANT SURVEY |
OMB No. 3145-0096 Expiration: 07/31/20xx |
Vacancy Ann. #: Position Status (temporary/permanent):
Position Title/Series/Grade:
INSTRUCTIONS Your completion of this form will be appreciated. Submission of this Information is voluntary and it will have no effect on the processing of your application. The data collected will be used only for statistical purposes to ensure that agency personnel practices meet the requirements of Federal law. Pursuant to 5 CFR 1320.5(b), an agency may not conduct or sponsor, and a person is not required to respond to an information collection unless it displays a valid OMB control number. The OMB control number for this collection is 3145-0096. NSF estimates that each respondent should take about 3 minutes to complete this survey, including time to read the instructions. You may have comments regarding this burden estimate or any other aspect of this survey, including suggestions for reducing this burden. If so, please send them to NSF Reports Clearance Officer, NSF, Office of the General Counsel, Room 1265, 4201 Wilson Blvd., Arlington, VA. 22230.
PRIVACY ACT INFORMATION GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal records and forms that solicit personal information. AUTHORITY - Section 7201 of title 5 of the U.S. Code and Section 2000e-16 of title 42 of the U.S. Code.
PURPOSE AND ROUTINE USES The information is used for research and for a Federal Equal Opportunity Recruitment Program (FEORP) to help insure that agency personnel practices meet the requirements of Federal law. Address questions concerning this form and its uses to the Privacy Act Officer, National Science Foundation, Arlington, VA 22230. |
1. Today's Date:
2. Year of Birth:
3. How did you learn about this particular position for which you are applying? Check all that apply:
01 - Friend or relative working at the National Science Foundation
02 - While serving on a National Science Foundation panel
03 - Career or Job Fair
If “yes” please specify:
04 - “NSF Updates” or other NSF subscriber service
If “yes” please specify:
05 - Office of Personnel Management’s USAJOBS
06 - NSF Careers Website
07 - Newspaper, professional journal or magazine
If “yes” please specify:
08 - Higher Education Recruitment Consortium (HERC)
09 - LinkedIn
10 - Twitter
11 - Facebook
12 - YouTube
13 - Online Search Engine
14 - Other
If yes please specify:
4. Which of the following describes your ethnicity? Please select only one:
Hispanic or Latina/o. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
B. Not Hispanic or Latina/o.
5. Which of the following describes your race? Please select one or more:
A. American Indian or Alaska Native. 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.
B. 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, and Vietnam.
C. Black or African American. A person having origins in any of the black racial groups of Africa.
D. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
E. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
6. Sex (check the appropriate box.) F - Female M - Male
7. Disability/Serious Health Condition
The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.
A. Do you have any of the following? Check all boxes that apply to you:
01 - Deaf or serious difficulty hearing
02 - Blind or serious difficulty seeing even when wearing glasses
03 - Missing an arm, leg, hand, or foot
04 - Paralysis: Partial or complete paralysis (any cause)
05 - Significant Disfigurement: for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders
06 - Significant Mobility Impairment: for example, uses a wheelchair, scooter, walker or uses a leg brace to walk
07 - Significant Psychiatric Disorder: for example, bipolar disorder, schizophrenia, PTSD, or major depression
08 - Intellectual Disability (formerly described as mental retardation)
09 - Developmental Disability: for example, cerebral palsy or autism spectrum disorder
10 - Traumatic Brain Injury
11 - Dwarfism
12 - Epilepsy or other seizure disorder
13 - Other disability or serious health condition: for example, diabetes, cancer, cardiovascular disease, anxiety disorder, or HIV infection; a learning disability, a speech impairment, or a hearing impairment
If you did not select one of the options above, please indicate whether.
None of the conditions listed above apply to me.
I do not wish to answer questions regarding disability/health conditions.
If you have indicated that you have one of the above conditions, you may be eligible to apply under Schedule A Hiring Authority. For more information, please see http://www.opm.gov/policy-data-oversight/disability-employment/hiring/.
If applicant checks the box #13 for “other disability or serious health condition,” the applicant will be taken to Section A.1.
Section A.1: Other Disability or Serious Health Condition (Optional). You indicated that you have a disability or a serious health condition in box #13. If you are willing, please select any of the conditions listed below that apply to you. As explained above, your responses will not be shown to the panel rating the applications, to the selecting official, or to anyone else who can affect your application. All responses will remain private to the extent permitted by law. See the Privacy Act Statement below for more information.
Please check all that apply:
01 - I do not wish to specify any condition.
02 - Alcoholism
03 - Cancer
04 - Cardiovascular or heart disease
05 - Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment
06 - Depression, anxiety disorder, or other psychological disorder
07 - Diabetes or other metabolic disease
08 - Difficulty seeing even when wearing glasses
09 - Hearing impairment
10 - History of drug addiction (but not currently using illegal drugs)
11 - HIV Infection/AIDS or other immune disorder
12 - Kidney dysfunction: for example, requires dialysis
13 - Learning disabilities or ADHD
14 - Liver disease: for example, hepatitis or cirrhosis
15 - Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder
16 - Morbid obesity
17 - Nervous system disorder: for example, migraine headaches, Parkinson’s disease, or multiple
sclerosis
18 - Non-paralytic orthopedic impairments: for example, chronic pain, stiffness, weakness in bones or joints, or some loss of ability to use parts of the body
19 - Orthopedic impairments or osteo-arthritis
20 - Pulmonary or respiratory impairment: for example, asthma, chronic bronchitis, or TB
21 - Sickle cell anemia, hemophilia, or other blood disease
22 - Speech impairment
23 - Spinal abnormalities: for example, spina bifida or scoliosis
24 - Thyroid dysfunction or other endocrine disorder
25 - Other. Please identify the disability/health condition, if willing:
FOR AGENCY USE AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
Agency Code: NSF Form 1232 (xx/2014)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | NATIONAL SCIENCE FOUNDATION |
Author | Bae, Kathy (Contractor) |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |