U.S. DEPARTMENT OF LABOR                                        FORM APPROVED: 

                                                                                                                                            OMB No. 1225-0072
           	APPLICANT BACKGROUND QUESTIONNAIRE     
The U.S. Department of Labor is requesting your completion of this form to assist the agency in evaluating and improving its efforts to publicize job openings and to encourage applications for employment from a diverse group of qualified candidates.   The Department will use the data you supply to determine how many applicants are from different groups and how many of these applicants are qualified for the job in question.  The Department will then assess the effectiveness of specific outreach efforts and means of communicating information on job vacancies in light of this information.

EFFECTS OF NONDISCLOSURE: Providing the information requested on this form is voluntary.  This information will have no effect on hiring decisions.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.	Information provided on this form will be used for program evaluation.  Personal identifying information will not be included in the tabulation of data in the DOL database. 

The public reporting burden for this collection of information is estimated to average 3 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 this burden to the U.S. Department of Labor, Human Resource Services Center, FPB, Washington, D.C. 20210; and the Office of Management and Budget, Paperwork Reduction Project, Washington, D.C. 20503.

Solicitation of this information is in accordance with  5 CFR Section 720, “Federal Equal Opportunity Recruitment Program” (FEORP).  	

PLEASE COMPLETE THE FOLLOWING:
Name:

	
 Sex:                      
                 ______ Male       ______ Female
		
Title, Grade, and Announcement Number Of Position for which applying:

ETHNIC  SELF-IDENTIFICATION
      Are you Hispanic or Latino?    (Definition: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
	______ Yes     ______  No

RACE SELF-IDENTIFICATION
Please read the descriptions, then mark one or more races to indicate what you consider yourself to be. 

_____ 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.
___ 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		A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
             Pacific Islander		Pacific Islands.
___ White			A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.        	

SOURCE OF INFORMATION ABOUT THIS VACANCY:     (Check all that apply)

____  1.  Magazine
____  2.  Newspaper
____  3.  Radio/Television Broadcast
____  4.  Agency Personnel Office
____  5.  State Employment Office
____  6.  Government Recruitment at School
____   7.   Federal, State, or Local Job Info. Center
____   8.   Friend or Relative Working for the Agency
____   9.   www.USAJOBS.gov
____ 10.   www.dol.gov or www.dol.gov/jobs 
____ 11.   Federal/DOL Jobsline (phone)
____ 12.   Other