Form FF-256-FY-21-100 Equity Demographics Questions

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0154
Expiration Date: 07/31/2025

EQUITY DEMOGRAPHICS QUESTIONS
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 5 minutes per response. The burden estimate includes the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
submitting this form. This collection of information is voluntary. You are not required to respond to this collection of information
unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and
any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal
Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, Paperwork Reduction Project (1660-0154)
NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT
AUTHORITY: FEMA is authorized to collect the information requested on this form pursuant to the following legal authorities: The
Robert T. Stafford Disaster Relief and Emergency Act, Pub. L. 93-288; 44 CFR §206.110 implements the policy and procedures set
forth in section 408 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. § 5174, as amended. 44 CFR
Part 16, Enforcement of Nondiscrimination on the Basis of [Disability] in Programs or Activities Conducted by the Federal
Emergency Management Agency, implements Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794, and the
disability-related non-discrimination provisions set forth in §§ 308 and 309 of the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, as amended, 42 U.S.C. §§ 5151 and 5152. DHS Directive Number 065-01, Nondiscrimination for Individuals with
Disabilities in DHS-Conducted Programs and Activities (Non-employment) issued 9/25/2013. The Robert T. Stafford Disaster Relief
and Emergency Assistance Act, as amended, 42 U.S.C. §§ 5121-5207; 6 U.S.C. 776-77; The Homeland Security Act of 2002, 6
U.S.C. §§ 311- 321j; Reorganization Plan No. 3 of 1978; 4 U.S.C. §§ 2904 and 2906; 44 CFR § 206.2(a)(27); The Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193); the Government Performance and Results Act,
Pub. L. 103,62, as amended; Executive Order 12862, Setting Customer Service Standards, dated September 11, 2003; Executive
Order 13411, Improving Assistance for Disaster Victims, dated August 29, 2006; and Executive Order 9397 as amended by
Executive Order 13478, Related to Federal Agency Use of Social Security Numbers, dated November 18, 2008.

DRAFT

FEMA requests Social Security Numbers (SSNs) pursuant to the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d)
and 7701(c)(1), as amended.
PURPOSE: This information is being collected for the primary purpose of analyzing demographic data to determine if any inequities
exist in the distribution of disaster assistance and to assess changes to policies and procedures to better assist underserved
communities if such inequities are found.
ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their
disaster assistance files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended.
Should FEMA disclose personal information outside of the Department, it will be consistent with the routine uses provided in the
Privacy Impact Assessment, DHS/FEMA/PIA-057 Individuals and Households Program Equity Analysis and System of Record
Notice, DHS/FEMA/SORN-017 Individuals and Households Program Equity Analysis. The Department's full list of system of records
notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.
VOLUNTARY RESPONSE: Providing responses to the demographic questions is voluntary. There are no consequences for not
providing the information. Failure to provide demographic data will not affect your potential eligibility for disaster assistance.
Please complete the following voluntary demographic questions. The responses provided to the below questions will not affect your
potential eligibility and any potential benefits.

FEMA Form FF-256-FY-21-100 (5/24)

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1. What is your race and/or ethnicity? Select all that apply and enter additional details in the spaces below
American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow
Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.
Asian - Provide details below.
Chinese
Asian Indian
Filipino
Enter, for example, Pakistani, Hmong, Afghan, etc.

Vietnamese

Korean

Black or African American - Provide details below.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.
Hispanic or Latino - Provide details below.
Mexican
Salvadoran
Cuban
Puerto Rican
Enter, for example, Colombian, Honduran, Spaniard, etc.

Dominican

Japanese

Somali

Guatemalan

DRAFT

Middle Eastern or North African - Provide details below.
Egyptian
Lebanese
Iranian
Syrian
Enter, for example, Moroccan, Yemeni, Kurdish, etc.

Iraqi

Native Hawaiian or Pacific Islander - Provide details below.
Native Hawaiian
Samoan
Chamorro
Tongan
Enter, for example, Chuukese, Palauan, Tahitian, etc.
White - Provide details below.
English
German
Irish
Italian
Enter, for example, French, Swedish, Norwegian, etc.

Polish

Israeli

Fijian

Marshallese

Scottish

2. Are you an enrolled member of a Tribal Nation?
Yes
No
If so, which Tribal Nation are you a member of?

3. What is your gender? Select all that apply
Male
Another Identity (e.g. non-binary or gender non-conforming)
Female
Transgender
4. Which of the following best describes your highest level of formal education?
High school graduate/GED
Some college
Did not complete high school
Bachelor's degree

Associate degree

Master's degree (or Graduate degree to include Master's and professional)

5. What is your marital status...
Never married
Widowed

FEMA Form FF-256-FY-21-100 (5/24)

Married or living with partner

Divorced

Doctoral degree

Separated

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