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

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Demographic Information

Applicants are requested to provide the following information for statistical purposes only. The information will be used to evaluate recruitment and hiring activities. SUBMISSION OF THIS INFORMATION IS VOLUNTARY. Your failure to do so will not affect the processing of your application. Your cooperation is appreciated.

3-873 (10-17-2007) OMB number

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. As indicated in the message at the top of the page, response to this request is voluntary. 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 5 minutes per response, including the time for reviewing instructions.

PRIVACY ACT STATEMENT

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

Purpose and Routine Uses: This information will only be seen by Human Resources and Equal Employment Opportunity officials who use the FBI automated hiring system to announce employment opportunities. Data summarizing all applicants for a position will be used to determine if we are effectively recruiting 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 applicant. No individual data is ever provided to selecting officials.

Effects of Nondisclosure: Providing this information is voluntary. No individual selections are made based on this information.

1. Ethnicity:

Are you a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins? This does not include persons of Portuguese culture or origin.

O Yes

O No

2. Race or national origin:

Please identify yourself by the category with which you most closely identify.

O American Indian or Alaska Native

A person having origins in any of the original peoples of North America, and who maintains cultural identification through community recognition or tribal affiliation.

O Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This area includes, for example, China, India, Japan, Korea,

the Philippine Islands and Samoa

O Black, not of Hispanic origin

A person having origins in any of the black racial groups of Africa. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish

cultures or origins (see Hispanic).

O Hispanic

A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins. Does not include persons of Portuguese culture or origin

O White, not of Hispanic origin

A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins (see Hispanic). Also includes those not included in other categories.

O Hawaiian or Pacific Islander

A person having origins in the Hawaiian Islands or the Pacific Islands; the Trust Territory Pacific Islands administered by the United States and comprised of the 2,000 islands in the Caroline, Mariana, and Marshall Islands.

O Two or More Races

A person having origins in two or more racial groups (biracial or multiracial).

3. Sex

1. O M - Male

2. O F - Female

4. Mental/Physical Disability: Do you have a mental or physical disability?

1. O Yes

2. O No

5. Targeted disability: Do you have a targeted disability?

1. O Yes

2. O No

6. If you checked “Yes” above, please identify your targeted disability.

1. O Blind

2. O Deaf

3. O Missing Extremity (s)

4. O Partial Paralysis

5. O Complete Paralysis

6. O Convulsive Disorder

7. O Mental Retardation

8. O Mental Illness

9. O Distortion of limbs and/or spine

10. O Other

Last updated 11/01/2007