DoDEA Form 5012 Department of Defense Dependents Schools (DoDDS) Volunta

DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS (DoDDS)
VOLUNTARY QUESTIONNAIRE
RETURN COMPLETED FORM TO:

OMB No. 0704-0370
OMB approval expires

DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS,
HUMAN RESOURCES CENTER
4040 NORTH FAIRFAX DRIVE, ARLINGTON, VA 22203-1634

The public reporting burden for this collection of information is estimated to average 2 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0370). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

1. NAME (Last, First, Middle Initial)

2. DATE OF BIRTH (YYYYMMDD)

NEEDS DD 67
PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. Section 7201; 42 U.S.C. Section 2000e-16; Office of Management and Budget 1997 Revisions to the
Standards for the Classification of Federal Data on Race and Ethnicity; and 20 U.S.C. 902, 903.
PRINCIPAL PURPOSE(S): This information is used to evaluate personnel/organizational measurement and selection methods;
implement agency affirmative employment programs; implement and evaluate agency Federal Equal Employment Recruitment
Progrms (including establishment of minority recruitment files); enable report to be prepared by race, sex, and national origin of
applicants, and for other uses consistent with the Office of Personnel Management Government-Wide Applicant Race, Sex, National
Origin and Disability Status Records (OPM/GOVT-7), available on the internet at
http://www.defenselink.mil/privacy/govwide/opm_govt-7.html.
ROUTINE USE(S): In addition to the disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, this record or
information contained therein may be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) and the DoD
"Blanket Routine Uses", prescribed as set forth at the beginning of the Office of the Secretary, DoD/Joint Staff compilation of
systems of records notices apply to this system, located at http://www.defenselink.mil/privacy/notices/osd, as well as the Office of
Personnel Management Routine Uses prescribed by OPM/GOVT-7, located above, as follows:
To the Equal Employment Opportunity Commission (EEOC) for use in examining agency compliance with affirmative action plan
and similar requirements imposed under EEOC authorities in connection with agency EEO programs;
To OPM maintaining records for personnel research or survey response in the production of summary descriptive statistics and
analytical studies in support of the functions for which the records are collected and maintained, or for related workforce studies;
To a Federal agency in response to its request for use in its Federal EEO Recruitment Program to the extent that the information is
relevant and necessary to the agency's efforts in identifying possible sources for minority recruitment.
DISCLOSURE: Your disclosure of the information requested on this form is voluntary. Failure to provide, or delay in providing, the
requested information has no impact on your employment status, but in the instance of missing information, other agency sources
may be used to obtain it, including visual observation (race), or knowledge of an individual's background (national origin), or from
other personnel records maintained under the OPM/GOVT-1 (General Personnel Records) system, also available on the internet at
http://www.defenselink.mil/privacy/govwide/opm_govt-1.html.
3. RACE, ETHNICITY, AND SEX. Please identify yourself in terms of the race, ethnicity, and sex categories below.
CATEGORIES AND DEFINITIONS
Race:
1 - 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.
2 - 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.
3 - Black or African American. A person having origins in any of the black racial groups of Africa.
4 - Native Hawaiian or other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
5 - White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Ethnicity:
1 - Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish cultures or
origins, regardless of race.
a. RACE (X all that apply)

1 - American Indian or Alaska Native
2 - Asian
3 - Black or African American
4 - Native Hawaiian or Other Pacific Islander
5 - White

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b. ETHNICITY (Enter code)

c. SEX (Enter code)

Are you Hispanic or Latino?
1 - Yes

M - Male

2 - No

F - Female

PREVIOUS EDITION IS OBSOLETE.

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DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS
VOLUNTARY QUESTIONNAIRE (Continued)
4. REPORTABLE DISABILITY
A physical or mental disability is NOT determined by a person's ability to perform his or her work but by a disability, or a history of
such disability, which is likely to cause the employee to experience difficulty in obtaining, maintaining or advancing in employment.
This does not apply solely to an employee's current position, but applies to the total career life cycle of that employee. (In the case of
multiple disabilities, choose the code which describes the impairment that would most likely result in such difficulties.)
Do you have a physical disability?
1 - YES
2 - NO

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5. HOW DID YOU LEARN ABOUT THE DODDS EMPLOYMENT OPPORTUNITIES? (X all that apply)

01 - Friend or relative working for DoDDS
02 - Friend or relative not working for DoDDS
03 - On-campus recruitment by DoDDS
04 - Direct mailing by DoDDS
05 - Government job information center
06 - State employment office
07 - Private information office
08 - State rehabilitation center
09 - Veterans association/employment office
10 - School placement officer
0A - Print advertisement - Name of publication:
0B - On-line information - Name of site:
0C - Professional conventions/meeting - Name of event:
0D - Other (please specify):

DoDEA FORM 5012 (BACK), 20080717 DRAFT

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