Revised Survey Instrument

U.S. Environmental Protection Agency

Applicant Background Questionnaire: Race, National Origin, Gender, and Disability Demographics

OMB Control Number: 2030-0045

PRIVACY ACT STATEMENT

EFFECT OF NONDISCLOSURE: Providing the information requested on this form is VOLUNTARY. This information will have no effect on hiring decisions.

GENERAL: This information is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a), for individuals completing Federal records and forms that solicit personal information.

AUTHORITY: Sections 1302, 3301, 3304, and 7201 of Title 5 of the U.S. Code. Title VII of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000e-16. The Rehabilitation Act of 1973, 29 U.S.C. § 791.

PURPOSE AND ROUTINE USES: The U.S. Environmental Protection Agency (EPA) is requesting your voluntary completion of this form for statistical and affirmative action/nondiscrimination purposes. The information will be used to evaluate EPA’s recruitment and hiring activities. 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. The data will be used for equal employment opportunity purposes, including the recruitment, hiring, placement, and advancement of a diverse workforce. Only summary data is reported, and only in a format which can not be broken out by individual applicants. No individual data is ever provided to selecting officials.

PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq.) requires the U.S. Environmental Protection Agency to inform you that this information is being collected for planning and assessing affirmative employment program initiatives. Response to this request is voluntary. The information will be used to evaluate EPA’s recruitment and hiring activities. Your failure to do so will not affect the processing of your application. This information will not be used for any other purpose. An agency may not conduct or 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 2 minutes per response, including the time for reviewing instructions. Direct comments regarding the burden estimate or any other aspect of this form to the U.S. Environmental Protection Agency, Office of Civil Rights, 1200 Pennsylvania Avenue, N.W., MC-1201A , Washington, DC 20460. Your cooperation is appreciated.

If you are returning to this page to view or update your information, please be advised that for privacy reasons, your previous answers are not viewable.

Please provide answers to the following questions:

1. Vacancy Announcement Number:

2. Position Title:

3. What is your grade level if you are a Federal employee? __________

4. Please indicate your gender.

 Male

 Female

5. Ethnicity: Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto

Rican, South or Central American, or other Spanish culture or origin, regardless of race)?

 Yes

 No

Race: Please select one or more of the racial category or categories with which you most closely identify by placing an “X” in the appropriate box(es).

	Name of Category	Definition of Category
6. 	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.
7. 	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.
8. 	Black or African American	A person having origins in any of the black racial groups of Africa.
9. 	White	A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
10. 	Native Hawaiian or Other Pacific Islander	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

11. Disability: Do you have a disability?

 Yes

 No

12. If you checked “Yes” above, is your disability one of the targeted disabilities listed below?

Please check all that apply

1. Blind

2. Deaf

3. Missing Extremity(ies)

4. Partial Paralysis

5. Total Paralysis

6. Convulsive Disorder

7. Mental Retardation

8. Mental Illness

9. Distortion of limb or spine

Thank you for your voluntary cooperation.