Form to Assist in Assessment of USDA Compliance with Civ

Approved OMB No. 0503-0019

U.S. Department of Agriculture

Form to Assist in Assessment

of USDA Compliance with Civil Rights Laws

QUESTIONNAIRE

The purpose of this questionnaire is to gather race, ethnicity, and gender information about persons who apply and participate in this USDA program. The information you provide will not be used when reviewing your application or when determining whether you are eligible to participate in this program. This is a voluntary questionnaire. You are not required to give this information, but we hope you will because the information you give will be used to improve the operation of this program, to help USDA design additional opportunities for program participation, and to monitor enforcement of laws that require equal access to this program for eligible persons. If you have previously provided this information to USDA please DO NOT fill out this form. Your information will be kept private to the extent permitted by law. Thank you for your response.

1. What is your name? __________________________________________________

2. Legal Residence: ____________________________________________________

_____________________________________________________

3. What is your gender? ____ Male ____ Female

Please answer BOTH question 4 and question 5 below about ethnicity and race. For this questionnaire, Hispanic or Latino origins are not races.

4. Ethnicity: ____ Hispanic or Latino

____ Not Hispanic or Latino

5. What is your race? Mark all that apply.

_____ American Indian or Alaska Native

_____ Asian

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ White

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 0503-0019. 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.