Form to Assist in Assessment of USDA Compliance with Civ

OMB No. 0503-0019

Expiration Date: xx-xx-xxxx

United States Department of Agriculture

Questionnaire to Assist in the
Assessment of USDA Compliance with Civil Rights Laws

PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, an agency may not conduct, 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 0503-0019. 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.

QUESTIONNAIRE

This form is used by USDA agencies, including FSA, NRCS, RBS, RHS, and RUS to gather race, ethnicity, and gender information from program participants. For participants that are entities, complete a separate form for each member.

The purpose of this questionnaire is to gather race, ethnicity, and gender information about persons who apply and participate in this USDA program. The information you provide will not be used when reviewing your application or when determining whether you are eligible to participate in this program.

This is a voluntary questionnaire. You are not required to provide this information, but we hope you will because the information you provide will be used to:

• improve the operation of this program;
• to help USDA design additional opportunities for program participation; and
• to monitor enforcement of laws that require equal access to this program for eligible persons.

If you have previously provided this information to USDA, please DO NOT fill out this form. Your information will be kept private to the extent permitted by law. Thank you for your response.

1. Enter your full legal name:

2. Enter your current address:

3. Select your gender.
Male
Female

Please answer BOTH question 4 and question 5 below about ethnicity and race. For this questionnaire, Hispanic or Latino origins are not races.

4. Select your appropriate ethnicity.
Hispanic or Latino
Not Hispanic or Latino

5. Select your appropriate race. Multiple races may be selected.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

PRIVACY ACT STATEMENT (5 U.S.C. 552a)

Purpose: The Privacy Act of 1974 requires that the Office of Assistant Secretary for Civil Rights (OASCR) provide the following statements to each individual from whom it requests information. Authority: Collection of this information is authorized by the regulations of the EEOC, 29 C.F.R. § 1614. The submission of this information is voluntary, but the failure to do so may hamper the investigation of a claim and could also lead to dismissal of the complaint. Routine Uses: The information collected will be used to determine whether your complaint is acceptable for investigation and in connection with any subsequent investigation and processing of your complaint. Disclosure: A copy of this complaint will be provided to the Civil Rights office of the agency against whom it is filed. This form may be shown to any individual who may be required by regulations, policies or procedures of the EEOC and/or OASCR to provide information in connection with this complaint. Other disclosures may be: (a) to respond to a request from a :of Congress regarding the status of the complaint or appeal; (b) to respond to a court subpoena and/or refer to a district court in connection with a civil suit; (c) to disclose information to authorized officials or personnel to adjudicate a complaint or appeal; or (d) to disclose information to another Federal agency or to a court or third party in litigation when the Government is party to a suit before court.

NONDISCRIMINATION ACT STATEMENT

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; or (2) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

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