FS-1700-5 Optional Ethnicity Questionnaire

USDA Forest Service FS- 1700-5 (Rev. 01/2014)

OMB 0596-0207 (Expiration xx/20xx)

OPTIONAL ETHNICITY QUESTIONNAIRE

The USDA Forest Service is gathering the following information to include in an annual report to Congress and we would appreciate your assistance. Providing this information is strictly voluntary, and your privacy is protected.

This information is used to determine if our public/program outreach efforts are reaching all segments of the population, consistent with Federal equal opportunity laws.

1. Were you provided with helpful information about USDA Forest Service program opportunities?

Yes No

2. Did you receive the information you were seeking, and in the preferred language?

Yes No If No, which language is preferred? ____________________

3. Were procedures for applying and receiving services from the USDA Forest Service described clearly and simply?

Yes No

4. Ethnicity (select 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

5. Race (select 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.

6. Do you have a disability?

Yes  

No

BURDEN AND NONDISCRIMINATION STATEMENTS

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0207. The time required to complete this information collection is estimated to average 2 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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