Form FR 28s FR 28s Applicant's Voluntary Self-Indentification Form

Board of Governors
of the Federal Reserve System

Applicant's Voluntary
Self-Identification Form

OMB No. 7100-0181
Average hours per response 1 minute
Approval expires December 31, 2007

The Board of Governors of the Federal Reserve System (Board) is requesting that you furnish this information under the
authority of 42 U.S.C. 2000e-16, which requires that Federal employment practices be free of discrimination and provide
equal employment opportunity for all. Your providing of this information is strictly voluntary. Your failure to do so will have
no effect on the decision to hire you or on your employment with the Board. The information you provide on this form will
be kept in a confidential file separate from your application for employment and will not be shared with the selecting official
or other persons who will make the hiring decision.
GENDER
Female

Male

Please respond to the ethnicity question and race identification below.
ETHNIC SELF IDENTIFICATION
Are you Hispanic or Latino?

Yes

No

If yes, please select from the following:

Cuban

South or Central American

Mexican

Other Spanish Culture

Puerto Rican
RACE SELF-IDENTIFICATION (Mark one or more)
American Indian or Alaskan 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 Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
PRIVACY ACT STATEMENT
Collection of this information is authorized by 42 U.S.C. 2000e-16 and 12 CFR part 268. The information will be used in
planning and monitoring equal employment opportunity programs at the Board, including preparing statistical reports
regarding race, gender and national origin of applicants. Providing this information is voluntary and failure to provide the
information will have no effect on your application. Disclosure of the information may be made to the Equal Employment
Opportunity Commission; to another federal agency, a court or a party in litigation, when the Board or the United States is
a party to the litigation; in response to a request for discovery or for appearance of a witness, information that is relevant to
the subject matter involved in a pending judicial or administrative proceeding; to contractors, grantees or volunteers
performing work on a contract, service, grant, cooperative agreement or job for the Board; to a congressional office from
the record of an individual in response to an inquiry from the congressional office made at the request of the individual; and
in accordance with any other routine uses of the records specified in the Board’s system of records notice “FRB-General
Personnel Records,” 68 Federal Register 22,381.

Name (Last, First, Middel Initial)

Signature

Date

Title, Grade, Announcement Number of Position for which you are applying
FR 28s (12/04)