Form 3035 Applicant Background Survey

OMB Control No. 3095-0045

Expiration date: 05/31/2007

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

APPLICANT BACKGROUND SURVEY

General Instructions: The information from this survey is used to help ensure that our recruitment efforts are reaching all segments of the population, as required by Federal law. This is vital information not available from any other source – we can only get it directly from you. The information you provide will be used for statistical purposes only and will in no way affect your application or selection. None of the information you provide is released to anyone who can affect your application. Please answer each question to the best of your ability and either return the form with your application package or mail it in a separate envelope to the same address. Completion of this form is voluntary.

1. Vacancy Announcement No.:      

2. Position Title:      

3. Name (Last, First, MI):      

4. How did you learn about this position? (Please check one.):

01. USAJobs Website	08. Professional Organization
02. NARA Website	09. NARA Human Resources Office
03. Other Website or Listserv (Specify)      	(bulletin board or other announcement)
	10. Federal, State, or Local Employment Office/
04. Newspaper or Other Print Publication Service	Job Information Center
05. Mailing to your organization or school	11. Private Employment Office/Information Service
06. Job Fair or Recruitment Visit	12. Word of Mouth
to your organization or school	13. Other (Specify)      
07. School or college counselor or other official

5. Identify yourself in each category (Check the appropriate boxes.):

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race (Check one or more.): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Sex: Male Female

6. Do you have a disability? Yes No

If yes, please check one of the following:

01. Deaf	06. Convulsive Disorder
02. Blind	07. Mental Retardation
03. Missing Limb/Extremity	08. Mental Illness
04. Partial Paralysis	09. Distortion of Limb and/or Spine
05. Total Paralysis	10. My disability is not listed.

SEE BACK OF THIS FORM FOR THE PRIVACY ACT STATEMENT,

PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS

PRIVACY ACT STATEMENT

GENERAL: This information is provided pursuant to Public Lay 93-579 (Privacy Act of 1974), for individuals completing Federal records and forms that solicit personal information.

AUTHORITY: Section 1302, 3301, 3304, and 7201 of Title 5 of the U.S. Code.

PURPOSE AND ROUTINE USES: The form will only be seen by National Archives and Records Administration Personnel and Equal Employment Opportunity officials. Data summarizing all applicants for a position will be used to determine if we are effectively recruiting from all portions of the country, in conformance with the requirements of Federal law. Only summary data is reported, and only in a format which cannot be broken out by individual applicants. No individual data is ever provided to selecting officials. The form will be destroyed after the position is filled.

EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. No individual personnel selections are made based on this information.

PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS

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 of 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 5 minutes per response, including the time for reviewing instructions. Direct comments regarding the burden estimate or any other aspect of this form to the National Archives and Records Administration (NHP), 8601 Adelphi Rd., College Park, MD 20470-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

NARA Form 3035 (03/07) Front