DEMOGRAPHIC INFORMATION ON APPLICANTS OMB No.:
Expiration Date:
Vacancy Announcement No.:
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Position Title:
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YOUR PRIVACY IS PROTECTED
This information is used to determine if our equal employment opportunity efforts are reaching all segments of the population, consistent with Federal equal employment opportunity laws. Responses to these questions are voluntary. Your responses will not be shown to the panel rating the applications, to the official selecting an applicant for a position, or to anyone else who can affect your application. This form will not be placed in your Personnel file nor will it be provided to your supervisors in your employing office should you be hired. The aggregate information collected through this form will be kept private to the extent permitted by law. See the Privacy Act Statement below for more information.
Completion of this form is voluntary. No individual personnel selections are made based on this information. There will be no impact on your application if you choose not to answer any of these questions.
Thank you for helping us to provide better service.
1. How did you learn about this position? (Check One):
Agency Internet Site recruitment
Private Employment Web Site
Other Internet Site
Job Fair
Newspaper or magazine
Agency or other Federal government on campus
School or college counselor or other official
Friend or relative working for this agency .
Private Employment Office
Agency Human Resources Department (bulletin board or other announcement)
Federal, State, or Local Job Information Center
Other
2. Sex (Check One):
Male
Female
3. Ethnicity (Check One):
Hispanic or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
4. Race (Check all that apply):
American Indian or Alaska Native - a person having origins in any of the original peoples of North or 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, or Vietnam.
Black or African American - a person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander - a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.
White - a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
5. Disability/Serious Health Condition
The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.
A. Do you have any of the following? Check all boxes that apply to you:
□ Deaf or serious difficulty hearing
□ Blind or serious difficulty seeing even when wearing glasses
□ Missing an arm, leg, hand, or foot
□ Paralysis: Partial or complete paralysis (any cause)
□ Significant Disfigurement: for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders
□ Significant Mobility Impairment: for example, uses a wheelchair, scooter, walker or uses a leg brace to walk
□ Significant Psychiatric Disorder: for example, bipolar disorder, schizophrenia, PTSD, or major depression
□ Intellectual Disability (formerly described as mental retardation)
□ Developmental Disability: for example, cerebral palsy or autism spectrum disorder
□ Traumatic Brain Injury
□ Dwarfism
□ Epilepsy or other seizure disorder
□ Other disability or serious health condition: for example, diabetes, cancer, cardiovascular disease, anxiety disorder, or HIV infection; a learning disability, a speech impairment, or a hearing impairment
If you did not select one of the options above, please indicate whether.
□ None of the conditions listed above apply to me.
□ I do not wish to answer questions regarding disability/health conditions.
If you have indicated that you have one of the above conditions, you may be eligible to apply under Schedule A Hiring Authority. For more information, please see http://www.opm.gov/policy-data-oversight/disability-employment/hiring/#url=Schedule-A-Hiring-Authority .
If an applicant checks the box for “other disability or serious health condition,” the applicant will be taken to Section A.1.
A.1. Other Disability or Serious Health Condition (Optional)
You indicated that you have a disability or a serious health condition. If you are willing, please select any of the conditions listed below that apply to you. As explained above, your responses will not be shown to the panel rating the applications, to the selecting official, or to anyone else who can affect your application. All responses will remain private to the extent permitted by law. See the Privacy Act Statement below for more information.
Please check all that apply:
□ I do not wish to specify any condition.
□ Alcoholism
□ Cancer
□ Cardiovascular or heart disease
□ Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment
□ Depression, anxiety disorder, or other psychological disorder
□ Diabetes or other metabolic disease
□ Difficulty seeing even when wearing glasses
□ Hearing impairment
□ History of drug addiction (but not currently using illegal drugs)
□ HIV Infection/AIDS or other immune disorder
□ Kidney dysfunction: for example, requires dialysis
□ Learning disabilities or ADHD
□ Liver disease: for example, hepatitis or cirrhosis
□ Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder
□ Morbid obesity
□ Nervous system disorder: for example, migraine headaches, Parkinson’s disease, or multiple sclerosis
□ Non-paralytic orthopedic impairments: for example, chronic pain, stiffness, weakness in bones or joints, or some loss of ability to use parts of the body
□ Orthopedic impairments or osteo-arthritis
□ Pulmonary or respiratory impairment: for example, asthma, chronic bronchitis, or TB
□ Sickle cell anemia, hemophilia, or other blood disease
□ Speech impairment
□ Spinal abnormalities: for example, spina bifida or scoliosis
□ Thyroid dysfunction or other endocrine disorder
□ Other. Please identify the disability/health condition, if willing: _________
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
Privacy Act Statement: This Privacy Act Statement is provided pursuant to 5 U.S.C. 552a (commonly known as the Privacy Act of 1974). The authority for this form is 5 U.S.C. 7201, which provides that the Office of Personnel Management shall implement a minority recruitment program, by the Uniform Guidelines on Employee Selection Procedures, 29 C.F.R. Part 1607.4, which requires collection of demographic data to determine if a selection procedure has an unlawful disparate impact, and by Section 501 of the Rehabilitation Act of 1973, which requires federal agencies to prepare affirmative action plans for the hiring and advancement of people with disabilities. Data relating to an individual applicant are not provided to selecting officials. This form will be seen by Human Resource personnel in the Office of Personnel Management (who are not involved in considering an applicant for a particular job) and by Equal Employment Opportunity Commission officials who will receive aggregate, non-identifiable data from the Office of Personnel Management derived from this form. Purpose and Routine Uses: The aggregate, non-identifiable information summarizing all applicants for a position will be used by the Office of Personnel Management and by the Equal Employment Opportunity Commission to determine if the executive branch of the Federal Government is effectively recruiting and selecting individuals from all segments of the population. Effects of Nondisclosure: Providing this information is voluntary. No individual personnel selections are made based on this information. There will be no impact on your application if you choose not to answer any of these questions.
Paperwork Reduction Act Statement: 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 or 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 five (5) minutes per response, including the time for reviewing instructions. Direct comments regarding the burden estimate or any other aspect of this form to [INSERT: Agency name and address] and to the Office of Management Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.
| File Type | application/msword |
| File Modified | 2014-02-07 |
| File Created | 2014-02-07 |