OMB Control No: 0300-0010
Expires 8-31-97
Executive Office of the President
APPLICANT BACKGROUND SURVEY
Public reporting burden for this collection of information is estimated
to average 5 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. Send comments regarding this burden estimate
or any other aspect of this collection of
information, including suggestions for reducing this burden, to the
Executive Office of the President, and to the Office of Management and
Budget, Paperwork Reduction Project, Washington, DC, 20503.
GENERAL INSTRUCTIONS
This information from this survey is used to help insure that agency
personnel practices meet the requirements of Federal law. Your responses
are voluntary. Answer each of the questions to the
best of your ability. Please print entries using capital letters only.
Read each item thoroughly before filling in the answer.
Position and Announcement # for which you are applying:
Date of your application:
Year of Birth:
How did you learn of this Position/Announcement?
PRIVACY ACT INFORMATION
General
This information is provided pursuant to Public Law 9305 79 (Privacy Act
of 1974), December 31, 1974, for individuals completing Federal records
and forms that solicit personal information.
PURPOSE AND ROUTINE USES
This information is used for research and for a Federal Equal Opportunity
Recruitment Program (FEORP) to help ensure that agency personnel
practices meet requirements of Federal Law.
EFFECTS OF NONDISCLOSURE
Providing this information is voluntary. No individual personnel
selections are made based on this information.
Please read the subcategories carefully, then categorize yourself in
terms of race, ethnicity, disability, and sex, checking only one box in
each category.
RACE
___ 1. American Indian or Alaskan Native: A person having origins in any
of the original peoples of North America, and who maintains cultural
identification through tribal affiliation or community recognition.
___ 2. Asian or Pacific Islander: A person having origins in any of the
original peoples of the Far East, Southeast Asia, the Indian
subcontinent, or the Pacific Islands. This area includes, for
example, India, Japan, Korea, the Phillippine Islands, and Samoa.
___ 3. Black: A person having origins in any of the black racial
groups of Africa.
___ 4. White: A person having origins in any of the original peoples of
Europe, North Africa, or the Middle East.
ETHNICITY
___ Hispanic Origin: A person of Mexican, Puerto Rican, Cuban, Central
or South American, or other Spanish culture or origin regardless of race.
___ Not of Hispanic Origin
DISABILITY
Please provide information on your disability status by checking one of
the categories below:
___ 1. I do not have a disability
___ 2. Hearing Impairment
___ 3. Vision Impairment
___ 4. Missing Extremities
___ 5. Partial Paralysis
___ 6. Complete Paralysis
___ 7. Convulsive Disorder
___ 8. Mental Retardation
___ 10. Mental or Emotional Illness
___ 11. Severe Distortion of Limbs and/or Spine
___ 12. I have a disability, but it is not listed
GENDER
___ 1. Male
___ 2. Female