Form EEO-44 (03-06) EEO-44 (03-06) Applicant Background Survey

FORM APPROVED
OMB NO. 3220-0201

Railroad Retirement Board

APPLICANT BACKGROUND SURVEY
GENERAL INSTRUCTIONS

YOUR PRIVACY IS PROTECTED

In boxes 1 to 3, please print using capital
letters only. Read each item thoroughly
before checking the appropriate codes in
boxes 4 and 5. Enclose this form with your
application package or mail it directly to the
same address.

This information is needed to determine if our recruitment
efforts are reaching all segments of the population, as
required by Federal law. This is vital information not
available from any other source. We can only get it directly
from you.
Your voluntary responses are treated in a highly confidential
manner. They are not released to the panel rating the
applications, to the selecting official, to anyone else who can
affect your application, or to the public. This form will be
destroyed after the position is filled.

1. Vacancy Announcement No.:

2. Position Title:

Your responses are stored as a tally for the group of all
applicants for this vacancy in a manner that cannot be
associated with any individual application. No information
taken from this form is ever placed in a Personnel file or
Personnel database.

3. Name ( Last, First, MI ):

Thank you for helping us provide better service.

4. How did you learn about this position? (Check up to three boxes below)
01
02
03
04
05

£
£
£
£
£

Internet (e.g. USAJOBS)
Agency Personnel Department
School or college counselor or other official
Media (e.g. newspaper, radio)
Private Employment Office

06
07
08
09
10

£
£
£
£
£

State Employment Office
Friend or relative working for this agency
Friend or relative not working for this agency
Professional organization
Other (Specify) __________________________

5. Identify yourself in each category below: (Check the appropriate boxes)
Ethnicity:

Race: (check one or more)

Sex:

£

Hispanic or Latino

£

Male

£

Not Hispanic or Latino

£
£
£
£
£

£

Female

Do you have a disability?

£

Yes

£

No

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

If yes, do you have a targeted* disability?

£

Yes

£

No

*The Equal Employment Opportunity Commission targets the following disabilities for
extra recruitment efforts: Deaf, Blind, Missing Extremities, Partial/Complete Paralysis,
Convulsive Disorders, Mentally Retarded, Mental Illness or Distortion Limb/Spine.

SEE BACK OF THIS FORM FOR THE PRIVACY ACT STATEMENT,
PAPERWORK REDUCTION ACT STATEMENT AND PUBLIC BURDEN STATEMENT
FORM EEO-44 (03-06)
Page 1 of 2

PRIVACY ACT STATEMENT
GENERAL: This information is provided pursuant to Public Law 93-579 (Privacy Act of
1974), for individuals completing Federal records and forms that solicit personal information.
AUTHORITY: Sections 1302, 3301, 3304, and 7201 of Title 5 of the U.S. Code.
PURPOSE AND ROUTINE USES: The form will only be seen by Railroad Retirement Board
Human Resources Personnel and Equal Employment Opportunity officials. Data
summarizing all applicants for a position will be used to determine if we are effectively
recruiting from all portions of the country, 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 applicants. No individual data is ever provided to selecting officials.
EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. No individual
personnel selections are made based on this information

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. Response to this request is voluntary. We estimate this form takes an
average of 5 minutes to complete, including the time for reviewing the instructions, and
reviewing the completed form. Federal agencies may not conduct or sponsor, and
respondents are not required to respond to, a collection of information unless it displays a
valid OMB number. If you wish, send comments regarding the accuracy of our estimate or
any other aspect of this form, including suggestions for reducing the completion time, to
Chief of Information Resources Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 60611-2092. DO NOT SEND COMPLETED FORMS TO THIS
ADDRESS.

FORM EEO-44 (03-06)
Page 2 of 2