2105-0557 US Department of Transportation Applicant Background Que

OMB No. 2105-0557
Expiration: 08/31/2009

U.S. DEPARTMENT OF TRANSPORTATION

APPLICANT BACKGROUND QUESTIONNAIRE
The U.S. Department of Transportation requests that you voluntarily complete this form to
assist the agency in evaluating and improving its efforts to publicize job openings and to
encourage employment applications from a diverse group of qualified candidates. The
Department will use the data you supply to determine how many applicants are from different
groups and how many of these applicants are qualified for the job in question. The Department
will then assess the effectiveness of specific outreach efforts and means of communicating
information on job vacancies in light of this information. Personal identifying information will
not be included in the tabulation of data.
The completion of this form is voluntary. This information will have no effect on the
processing of your application or hiring decisions.
PRIVACY ACT INFORMATION: This information is provided pursuant to Public Law 93579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal records and
forms that solicit personal information. Authority: Section 7201 of title 5 of the U.S. Code
and Section e-16 of title 42 of the U.S. Code

PLEASE COMPLETE THE FOLLOWING:
Name:

According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information is 2105-0557.
The public reporting burden for this collection of information is estimated to average 4
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 U.S. Department of Transportation, Departmental Human Resources
Office, 400 7th St, SW., Washington, DC 20590; and the Office of Management and
Budget, Paperwork Reduction Project, Washington, D.C. 20503.
Solicitation of this information is in accordance with “Federal Equal Opportunity
Recruitment Program” (FEORP), found in part 720 of title 5, Code of Federal
Regulations.

Sex:

__ Male

__ Female

Title, Grade, and Announcement Number of position for which you are applying:

Do you have a disability?

___ Yes

___ No

If yes, please provide information on your disability by selecting the appropriate category:
__ I do not choose to identify my disability
__ Complete paralysis
__ Total Deafness
__ Convulsive disorder
__ Blind/uncorrectable visual impairment
__ Mental retardation
__ Missing extremity(ies)
__ Mental or emotional illness
__ Partial paralysis
__ Severe distortion of limbs or spine
__ I have a disability but it is not listed
Are you of Hispanic or Latino origin? __ Yes ___ No
Please select one or more racial categories:
A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains cultural identification through tribal
affiliation or community attachment.
A person having origins in any of the original peoples of the Far East, Southeast Asia,
__ Asian
or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and Vietnam.
A person having origins in any of the black racial groups of Africa.
__ Black or African American
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
__ Native Hawaiian or other Pacific Islander
other Pacific Islands.
A person having origins in any of the original peoples of Europe, the Middle East, or
__ White
North Africa.
How did you find out about this vacancy? (Select all that apply)
____ 8. Friend or Relative Working for DOT
____ 1. Magazine/Newspaper
____ 9. Friend or Relative Not Working for DOT
____ 2. Radio/Television Broadcast
____10. DOT’s Careers in Motion Web Site
____ 3. DOT Human Resources Office
(www.careers.dot.gov)
____ 4. State Employment Office
____ 11. Internet or Other Web Site
____ 5. Government Recruitment at School
____ 12. State Vocational Rehabilitation Agency or
____ 6. Attendance at Conference, Meeting, or Job
U.S. Dept. of Veterans’ Affairs
Fair (specify _______________________)
____ 13. Other (specify _____________________)
____ 7. Federal, State, or Local Job Information Center

__ American Indian or Alaska Native