Form BC-171 Additional Applicant Information

FORM

BC-171

OMB No.: XXXXXX
U.S. DEPARTMENTOF COMMERCE

(8-20-2018)

Economics and Statistics Administration

U.S. CENSUS BUREAU

ADDITIONAL APPLICANT
INFORMATION
Last name

Social Security Number
(Last four digits)

First name

YOUR PRIVACY IS PROTECTED
This information is used to determine if our equal employment opportunity efforts are reaching all segments of the
population, consistent with Federal equal employment opportunity laws. Responses to these questions are voluntary.
Your responses will not be shown to the selecting official or to anyone else who can affect your application. This form
will not be placed in your Personnel File nor will it be provided to your supervisors in your employing office should you
be hired. The aggregate information collected through this form will be kept private to the extent permitted by law. See
the Privacy Act Statement below for more information.
Completing this form in part or in its entirety is voluntary. No individual personnel selections are
made based on this information. There will be no impact on your application if you choose not to
answer any of these questions.
Thank you for helping us to provide better service.

1. Recruiting Sources – How did you hear about Census Bureau job opportunities? Mark (X) for
one box only.
National or Community organization – Specify
Federal, state, tribal government agency
Employment office/job service and information center
Census recruiter
Census jobs website
Internet advertisement
Social media
Toll-free Census phone number/jobs line
Census job mailing/postcard
Friend or relative working for Census

Friend or relative not working for Census
Brochure/poster/flyer
Job fair
Newspaper-advertisement
Newspaper-article
Radio
School or college
TV advertisement or news
Other – Specify

2. Ethnicity – Mark (X) for one box only.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
Not Hispanic or Latino

3. Race – Mark (X) all that apply.
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.
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.
Black or African American – a person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Paci c Islander – a person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific islands.
White – a person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.

4. Education (Mark (X) in highest education level):
No high school
Some high school – Did not graduate
High school diploma/GED
Technical degree/Trade school degree or certificate
Some College – Did not graduate

Associate’s degree
Bachelor’s degree
Master’s degree
Doctoral degree

5. 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.
Do you have any of the following? (Mark (X) all boxes that apply to you):
Deaf or serious difficulty hearing
Blind or serious difficulty seeing even when
wearing glasses
Missing an arm, leg, hand, or foot
Paralysis: Partial or complete paralysis (any cause)
Significant Disfigurement: for example, severe
disfigurements caused by burns, wounds, accidents,
or congenital disorders
Significant Mobility Impairment: for example, uses a
wheelchair, scooter, walker, leg brace(s) and/or other
supports

Significant Psychiatric Disorder: for example, bipolar
disorder, schizophrenia, PTSD, or major depression
Intellectual Disability (formerly described as mental
retardation)
Developmental Disability: for example, cerebral palsy
or autism spectrum disorder
Traumatic Brain Injury
Dwarfism
Epilepsy or other seizure disorder

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 – Indicate disability or serious
health condition below
Other Disability or Serious Health Condition (Optional) – Please mark all that apply.
You indicated that you have a disability or a serious health condition. 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 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.
I do not wish to specify any condition
Alcoholism
Cancer
Cardiovascular or heart disease
Crohn’s disease, irritable bowel syndrome,
or other gastrointestional impairment
Depression, anxiety disorder, or
other psychological disorder
Diabetes or other metabolic disease
Difficulty seeing even when wearing glasses
Hearing impairment
History of drug addiction (but not
currently using illegal drugs)
HIV Infection/AIDS or other immune disorder
Kidney dysfunction: for example, requires dialysis
Learning disabilities or ADHD
Liver disease: for example, hepatitis or cirrhosis
Lupus, fibromyalgia, rheumatoid arthritis, or other
autoimmune disorder

Morbid obesity
Nervous system disorder: for example, migraine
headaches, Parkinson’s disease, or multiple
sclerosis
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
Orthopedic impairments or osteo-arthritis
Pulmonary or respiratory impairment: for example,
asthma, chronic bronchitis, or TB
Sickle cell anemia, hemophilia, or other
blood disease
Speech impairment
Spinal abnormalities: for example, spina
bifida or scoliosis
Thyroid dysfunction or other endocrine disorder
Other. Please identify the disability/serious health
condition, if willing:

If you did not select one of the options above, please indicate:
I do not wish to identify my disability or serious
health condition.
I do not have a disability or serious health condition.
I have a disability or serious health condition,
but it is not listed on this form.

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FORM BC-171 (6-11-2018)

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
Privacy Act Statement: The collection of your personal information is authorized under 5 U.S.C. 7201, which provides
that the Office of Personnel Management shall implement a minority recruitment program, and by the Uniform Guidelines on
Employee Selection Procedures, 29 C.F.R. Part 1607.4, which requires collection of demographic data to determine if a
selection procedure has an unlawful disparate impact, and by Section 501 of the Rehabilitation Act of 1973, which requires
federal agencies to prepare affirmative action plans for the hiring and advancement of people with disabilities.
Personally identifiable information collected includes your education, race, ethnicity, disability, and medical information. Data
relating to an individual applicant are not provided to selecting officials.
The information provided to us may be shared with Census Bureau staff for the work-related purposes identified in this
statement as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a). The aggregate, nonidentifiable information
summarizing all applicants for a position will be used by the Office of Personnel Management and by the Equal Employment
Opportunity Commission to determine if the executive branch of the Federal Government is effectively recruiting and selecting individuals from all segments of the population and as per the Privacy Act System of Record Notice OPM/GOVT–7,
Applicant Race, Sex, National Origin, and Disability Status Records.
Providing this information is voluntary. No individual personnel selections are made based on this information. There will be
no impact on your application if you choose not to answer any of these questions.
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 five (5) minutes, including the time for reviewing instructions. Direct comments regarding the burden estimate or any
other aspect of this form to Paperwork Reduction Project 0607-0139, U.S. Census Bureau, 4600 Silver Hill Road, Field
Division-Correspondence Liaison, 5th floor, Washington, DC 20233-1500 or you may e-mail comments to
FLD.Decennial.Oversight@census.gov; use "Paperwork Reduction Project 0607-0139" as the subject and to the Office of
Management Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.
The eight digit OMB number on the first page of this form confirms our authority to collect this information.

FORM BC-171 (6-11-2018)

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