Form 12844 Survey Questionnaire

Survey Questionnaire

OMB Number 1545-1922

The data requested on this form will be used for statistical analysis to evaluate our recruiting program. Submission of this
information is voluntary. Please read and complete each question.
Circle One
Male
Female

Age

Location applying

Date

List positions applying for:
a
a

How did you learn about this position? Please circle only one:
1 Newspaper — Which one? _________________________

6 Friend or Relative working for IRS

2 Radio — What station? ____________________________

7 Friend or relative NOT working for IRS

3 TV — What station? ______________________________

8 Internet ______________________________________
(list web site, ex: USAJobs.opm.gov)

4 State Employment Office (TEC)

9 Billboard/Marquee

5 Agency Personnel Office (IRS)

10 Val-Pac
11 Other

The categories below are designed to identify your basic race and national origin. If you are of mixed racial and/or national
origin, identify yourself by the category with which you most closely identify yourself. Circle ONLY ONE code next to the
appropriate category.
Name of Category

Definition of Category

Code
C

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).

D

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.

B

A

E

A person having origins in any of the original peoples of the Far Island
East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This
area includes China, India, Japan, Korea, the Philippine Islands, and
Samoa.

Asian or Pacific Islander

American Indian or Alaskan Native

White, not of Hispanic origin

A person having origins in any of the original peoples of North America,
and who maintains cultural identification through community recognition
or tribal affiliation.
A person having origins in any of the original peoples of Europe, North
America, 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 persons not included in
other categories.

Privacy Act and Paperwork Reduction Act Notices- The information requested on this form will be used to update personnel records. Your name and/or social
security number is only used as an identifier (authorized under Executive Order 9397, dated November 1943.) Your response is voluntary. We ask for the information
on this form to carry out the mission of the Internal Revenue Service. We need the information to process your application for employment with the Internal Revenue
Service. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any
Internal Revenue law. Generally tex returns and return information are confidential, as required by code 6103. The time needed to complete this form will vary
depending upon the individual circumstances. The estimated average time to complete this form is 5 minutes. If you have comments concerning the accuracy of
this estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products
Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Form

12884 (Rev. 3-2005)

Catalog Number 30944Z

Department of Treasury — Internal Revenue Service