NARA Form 3035 (03-07)

OMB Control No. 3095-0045
Expiration date: 04/30/20 10

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

APPLICANT BACKGROUND SURVEY
General Instructions: The information fiom this survey is used to help ensure that our recruitment efforts are reaching all
segments of the population, as required by Federal law. This is vital information not available f?om any other source - we can
only get it directly fiom you. The information you provide will be used for statistical purposes only and will in no way affect your
application or selection. None of the information you provide is released to anyone who can affect your application. Please
answer each question to the best of your ability and either return the form with your application package or mail it in a separate
envelope to the same address. Completion of this form is voluntary.

1 1. Vacancy Announcement No.:
1 2. Position Title:

I
I

3. Name (Last, First, MI):

4. How did you learn about this position? (Please check one.):
08. Professional Organization
09. NARA Human Resources Office
(bulletin board or other announcement)
10. Federal, State, or Local Employment Office/
Job Information Center
11. Private Employment OfficelInformation Service
12. Word of Mouth
13. Other (Specify)

01. USAJobs Website
02. NARA Website
03. Other Website or Listserv (Specify)
04. Newspaper or Other Print Publication Service

[7 05. Mailing to your organization or school

rI

06. Job Fair or Recruitment Visit
to your organization or school
07. School or college counselor or other official

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

1

Ethnicity:
Hispanic or Latino
Not Hispanic or Latino

6. Do you have a disability?

Race (Check one or more.):

Sex:

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

Male
Female

No

If yes, please check one of the following:
[7 06. Convulsive Disorder

[7 01. Deaf
02. Blind

07. Mental Retardation

03. Missing LimbExtremity

08. Mental Illness

[7 04. Partial Paralysis

09. Distortion of Limb and/or Spine

[7 05. Total Paralysis

10. My disability is not listed.

SEE BACK OF THIS FORM FOR THE PRIVACY ACT STATEMENT,
PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS
NARA Form 3035 (03107) Front

OMB Control No. 3095-0045
Expiration date: 0413012010

PRIVACY ACT STATEMENT
GENERAL: This information is provided pursuant to Public Lay 93-579 (Privacy Act of 1974), for individuals completing
Federal records and forms that solicit personal information.
AUTHORITY: Section 1302,3301,3304, and 7201 of Title 5 of the U.S. Code.
PURPOSE AND ROUTINE USES: The form will only be seen by National Archives and Records Administration 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. The form will be destroyed after the position is filled.
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. An Agency may
not conduct of sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB Control Number.
The estimated burden of completing this form is 5 minutes per response, including the time for reviewing instructions. Direct
comments regarding the burden estimate or any other aspect of this form to the National Archives and Records Administration
(NHP), 860 1 Adelphi Rd., College Park, MD 20470-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

NARA Form 3035 (03107) Back