Form NSF-1232 Applicant Survey

NATIONAL SCIENCE FOUNDATION APPLICANT SURVEY

OMB No. 3145-0096 Expiration: 07/2008

Vacancy Ann. #:      Position Status (temporary/permanent):     

Position Title/Series/Grade:     

INSTRUCTIONS

Your completion of this form will be appreciated. Submission of this Information is voluntary and it will have no effect on the processing of your application. The data collected will be used only for statistical purposes to ensure that agency personnel practices meet the requirements of Federal law. Pursuant to 5 CFR 1320.5(b), an agency may not conduct or sponsor, and a person is not required to respond to an information collection unless it displays a valid OMB control number. The OMB control number for this collection is 3145-0096. NSF estimates that each respondent should take about 3 minutes to complete this survey, including time to read the instructions. You may have comments regarding this burden estimate or any other aspect of this survey, including suggestions for reducing this burden. If so, please send them to NSF Reports Clearance Officer, Division of Administrative Services, NSF, 4201 Wilson Blvd., Arlington, VA. 22230.

PRIVACY ACT INFORMATION

GENERAL - This information is provided pursuant to Public Law 93-579 (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 2000e-16 of title 42 of the U.S. Code.

PURPOSE AND ROUTINE USES

The information is used for research and for a Federal Equal Opportunity Recruitment Program (FEORP) to help insure that agency personnel practices meet the requirements of Federal law. Address questions concerning this form and its uses to the Privacy Act Officer, National Science Foundation, Arlington, VA 22230.

1. Today's Date:     2. Year of Birth:     

3. How did you learn about the particular position for which you are applying? (Check the appropriate box.)

01 - Newspaper (specify)     

02 - Contact with NSF Personnel Office

(Agency Bulletin Board or other Announcement)

03 - NSF-initiated personal contact

04 - Science Magazine, or other professional journal or magazine

(specify)     

05 - Affirmative Action Register

06 - Attendance at conference, meeting or job fair

(specify)     

07 - NSF recruitment at school or college

08 - Colleague referral

09 - NSF Bulletin

10 - Federal, State or local job information center

11 - State vocational rehabilitation agency or

Veterans Administration

12 - State employment office

13 - School or college counselor or other official

14 - Private job Information service

15 - Private employment service

16 - Friend or relative working at NSF

17 - Friend or relative not working at NSF

18 – NSF website

19 – Internet or other website

20 - Other (specify)     

5. Select the ethnic category with which you most closely identify:

1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

B. Not Hispanic or Latino.

4. Select one or more racial category with which you most closely identify:

A. 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.

B. 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.

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

D. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

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

6. Sex (check the appropriate box.) F - Female M - Male

7. Please provide Information on your disability status by checking the appropriate category below:

1. I do not have a disability; 2. Hearing impairment; 3. Vision impairment; 4. Missing extremities; 5. Partial paralysis;

6. Complete paralysis; 7. Convulsive disorder; 8. Mental retardation; 9. Mental or emotional illness; 10.Severe distortion of limbs and/or spine; 11.I have a disability but it is not listed.

…………………………………………………………………………………………………………………………………………

FOR AGENCY USE

Agency Code: ________________ __________________ __________________ __________________

AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER

NSF Form 1232 (7/2005)