Form HR-1225-0072 Applicant Background Questionaire

FORM APPROVED OMB No. 1225-0072

(Exp. 10-31-2008)

U.S. DEPARTMENT OF LABOR

APPLICANT BACKGROUND QUESTIONNAIRE

The U.S. Department of Labor is requesting your completion of this form to assist the agency in evaluating and improving its efforts to publicize job openings and to encourage applications for employment from a diverse group of qualified candidates, including minorities and persons with disabilities. 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. EFFECTS OF NONDISCLOSURE: Providing the information requested on this form is voluntary. This information will have no effect on hiring decisions. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

Information provided on this form will be used for program evaluation. Personal identifying information will not be included in the tabulation of data in the DOL database. The public reporting burden for this collection of information is estimated to average 3 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 Labor, Human Resource Services Center, FPB, Washington, D.C. 20210; and the Office of Management and Budget, Paperwork Reduction Project, Washington, D.C. 20503. Solicitation of this information is in accordance with 5 CFR Section 720, “Federal Equal Opportunity Recruitment Program” (FEORP).

PLEASE COMPLETE THE FOLLOWING:

Name:	Do you have a Disability?  Yes  No If You checked “Yes” above, is your disability one of the targeted disabilities listed below? Yes  No Blind Deaf Missing Extremity(s) Partial Paralysis Complete Paralysis Convulsive Disorder Mental Retardation Mental Illness Genetic or physical condition affecting limbs or spine
Sex:  Male  Female
Title, Grade, and Announcement Number Of Position for which applying:

ETHNIC SELF-IDENTIFICATION

Are you Hispanic or Latino? (Definition: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

 Yes  No

RACE SELF-IDENTIFICATION

Please read the descriptions, then mark one or more races to indicate what you consider yourself to be.

 American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

 Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

 Black or African American A person having origins in any of the black racial groups of Africa.

 Native Hawaiian or other A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other

Pacific Islander Pacific Islands.

 White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

SOURCE OF INFORMATION ABOUT THIS VACANCY: (Check all that apply)

____ 1. Magazine

____ 2. Newspaper

____ 3. Radio/Television Broadcast

____ 4. Agency Personnel Office

____ 5. State Employment Office

____ 6. Government Recruitment at School

____ 7. Federal, State, or Local Job Info. Center

____ 8. Friend or Relative Working for the Agency

____ 9. Internet

____ 10. Federal/DOL Jobsline

____ 11. Other