Form BC-170A Census Employment Inquiry-BC170A

Census Jobs!
U.S. DEPARTMENT OF COMMERCE • Economics and Statistics Administration • U.S. CENSUS BUREAU

The Census Bureau is an
Equal Opportunity Employer
WORK AS A CENSUS FIELD REPRESENTATIVE
The U.S. Census Bureau has employment opportunities for
survey field representatives and related positions to collect
survey data for the federal government. Census field
representatives may work varied schedules depending on
assignments and survey requirements.
DUTIES
You will be assigned households or persons in your local
area to contact and interview during a predetermined period
of the month. You will use a Census Bureau provided laptop
computer to record answers from the interview. We will
provide you training on how to operate the laptop computer
and how to record survey answers. A Census Bureau team
leader will accompany you on your first assignment to
provide on-the-job training.
The information you collect is confidential and
must not be disclosed to anyone who has not
sworn to protect Census Bureau information.
TRAINING
You will be required to complete a 10-30 hour self-study
before you attend your initial classroom training. Initial
classroom training may last 3-5 days and may require travel to
another city on government per diem. After your classroom
training you may receive on-the-job training, be required to
complete self-studies, and attend refresher-training sessions
periodically. You will be paid for time spent in training, and for
time and mileage required to attend training.
WHEN YOU WILL WORK
Your hours of work each month will vary depending on the
number of households you are assigned to interview.
Although you will typically have the flexibility to determine the
specific hours that you will be working, the work will usually
require evening and weekend work to meet deadlines. You
must be willing to work the hours necessary to complete an
assignment on schedule. Many positions will require that you
be willing to travel to a variety of neighborhoods and to
interview diverse groups. You need to be available to work
when the people you need to interview are home, but
generally no later than 9:00 p.m. Interviewing may require
driving in the evenings and during bad weather.

HOW CAN YOU QUALIFY FOR CENSUS SURVEY
WORK?
1. Noncitizens will only be considered for census jobs if
qualified citizens are not available, particularly in areas
where bilingual ability is a necessary qualification. You
must present documentation of employment eligibility.
The types of acceptable documentation are listed on the
reverse side of this form.
2. You must be 18 years of age or older.
3. You must have a valid Social Security number.
4. Applicants must take and pass a written basic skills test,
after which a mock interview and structured job interview
will be administered.
5. Most census jobs require the employee to conduct
face-to-face interviews with respondents. This involves
visiting respondents in a variety of residence types,
asking questions and recording responses.
6. Male applicants born after December 31, 1959, must be
registered with the Selective Service System.
7. The Census Bureau performs criminal background
checks and reviews criminal records (including
fingerprinting) as part of assessing applicants’ past
conduct and suitability for employment.
8. You will not engage in any political activity while on duty.
9. All non-census employment (including law and regulatory
enforcement jobs) will be reviewed on a case-by-case
basis for compatibility with Census Bureau employment.
10. Applicants must be available to work days, evenings,
and weekends. Since most people are not home during
the day, you will have to visit some homes during the
evening and on the weekends.

PAY
You will be paid for hours worked including time and mileage
in travel and for training. You also will be reimbursed for
authorized out of pocket expenses, for telephone and other
travel costs on official business; such as parking fees, bus
fares, etc. The method of payment is bi-weekly direct deposit
into your financial institution account.

For more information, contact:

BC-170A

FORM
(6-23-2011)

Instructions to prepare for the testing session
are on reverse side.

DRAFT #12 (06/23/2011)
BC-170A, Page 1 Base copy, solid Black ink

BC-170A, Page 1 Overlay, Pantone 280 (20% and 100%)

How do I complete the BC-170A, Census Employment
Inquiry?
1. Print clearly using a black or blue pen. We
cannot accept your form if it is not legible.
Print neatly in uppercase. For example
2. Follow the instructions provided with every item. If you do not
answer all questions fully and correctly, you may delay the
processing of your application.
3. Enter one letter or number within each white block or complete
the information on the line provided.
Here are a few explanatory notes for some of the items:
Page 1
Section A – Applicant Personal Data
4. Enter your State postal abbreviation for the state in which you
live, for example, MS for Mississippi.
10a. Enter your Date of Birth. For example, enter July 6, 1952 as
follows:
Month

Day

Year

What is the test like?
Each applicant interested in Census Bureau employment must
take a written test. One such test is called the Field Employee
Selection Aid. It consists of 32 questions designed to measure
the knowledge, skills, and abilities required to perform a variety
of census jobs. You will have 30 minutes to complete the
multiple choice test. Provided here are some sample questions
to help better prepare you for the test. If you pass the written
test, you will then participate in two interview exercises.
The test is physically accessible to people with disabilities.
Requests for reasonable accommodations for persons with
disabilities (such as sign language interpretation) should be
directed to the contact office and phone number on the front
of this form.
Sample Questions
1. A respondent tells you she just bought living room carpet
which is 20 feet long by 15 feet wide. If carpet is $6.00 per
square foot, how much did the new carpet cost?
A. $300
B. $1,800

C. $1,300
D. $890

ANSWER B

Instruction: Circle the letter of the answer which means the
same as the word in capital letters.
2. The answer the respondent gave was very TENTATIVE.
A. Surprising
C. Uncertain
ANSWER C
B. Convincing
D. Inappropriate

Page 2
Section C – Other Consideration
16a. Enter an (X) in the yes or no response box for: Are you
willing to work in the field? If you enter "yes" in the response
box, you will be considered for positions in the field. These
positions include working primarily outside the office
environment.
b. Enter an (X) in the yes or no response box for: Are you
willing to work in the office? If you enter "yes" in the
response box, you will be considered for positions in the
office. These positions include working primarily within the
office environment.
By entering a yes for both office and field positions, you
will be considered for positions in both those areas.

Can I receive veterans’ preference?
If you served on active duty in the United States military and
were separated under honorable conditions, you may be
eligible for veterans’ preference. To receive 5-point veterans’
preference, applicants must bring a copy of a completed
DD-214, Certificate of Release or Discharge from Active
Duty,to the testing site. To receive 10-point veterans’
preference, applicants must also bring a completed SF-15,
Application for Veterans’ Preference, with the appropriate
documentation as shown on the reverse of the SF-15.

Identification you need to bring to the testing site
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be unexpired.
LIST A
Documents that Establish Both Identity and
Employment Eligibility

1. U.S. Passport or U.S. Passport Card

LIST C
Documents that Establish
Employment Authorization

LIST B
Documents that Establish
Identity
OR 1. Driver’s license or ID card issued by a

2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
3. Foreign passport that contains a temporary I-551
stamp or temporary I-551 printed notation on a
machine-readable immigrant visa.
4. Employment Authorization Document
that contains a photograph (Form I-776).
5. In the case of a nonimmigrant alien authorized to
work for a specific employer incident to status, a
foreign passport with Form I-94 or Form I-94A
bearing the same name as the passport and
containing an endorsement of the alien’s
nonimmigrant status, as long as the period of
endorsement had not yet expired and the
proposed employment is not in conflict with any
restrictions or limitations identified on the form.
6. Passport from the Federated States of
MIcronesia (FSM) or the Republic of the
Marshall Island’s (RMI) with Form I-94 or
Form I-94A indicating nonimmigrant admission
under the Compact of Free Association
Between the United States and the FSM or RMI.

AND 1. Social Security Account Number card

State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
2. ID card issued by federal, state, or local
government agencies or entities
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
3. School ID card with a photograph
4. Voter’s registration card
5. U.S. Military card or draft record
6. Military dependent’s ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
9. Driver’s license issued by a Canadian
government authority
For persons under age 18 who are unable
to present a document listed above.
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record

other than one that specifies on the
face that the issuance of the card
does not authorize employment in the
United States.
2. Certificate of Birth Abroad issued by
the Department of State
(Form FS-545)
3. Certificate of Report of Birth issued
by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a state, county,
municipal authority or Territory of the
United States bearing an official seal
5. Native American tribal document
6. U.S. Citizen ID Card (Form I-197)
7. Identification Card for use of Resident
Citizen in the United States
(Form I-179)
8. Employment authorization document
issued by the Department of
Homeland Security

FORM BC-170A (6-23-2011)

BC-170A, Page 2 base copy, solid Black ink

BC-170A, Page 2 Overlay, Pantone 280 (20% and 100%)

NOTE – THE ACCURACY OF YOUR STATEMENTS WILL BE VERIFIED.
FORM BC-170A
(6-23-2011)

OMB No. 0607-0139

CENSUS EMPLOYMENT INQUIRY

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

Section A – APPLICANT PERSONAL DATA

1.

9.

Job Announcement Name and/or Job title:

Sex Mark (X) one box.
Male

Female

2.

10a. Date of birth

Social Security Number

Month

Day

Year

3. Name
Last Name

b.

First Name

State or Country

MI

11.
4.

Place of birth
City

Residence address
Street address or RFD number (Include apartment number, if any)

Are you a citizen or national of the United States?
Yes
No – Specify country

12.

Military Service
a. Do you claim veterans’ preference? Mark (X) one box.
No preference – Skip to item 14.

City

Yes – List period(s) of service
Month

County or Parish

Year

Month

Year

TO
State

5.

ZIP Code

Branch, Rank, Awards, Badges, or Campaign medals –

Mailing address (if different from item 4)
Street address or RFD number (Include apartment number, if any)

b. Veterans’ preference categories? Mark (X) one box.
5-point preference – Attach your DD-214 or other proof
10-point preference – Follow instruction below
If you claim 10-point preference, you must complete a
Standard Form 15, which is available at any Federal Job
Information Center. ATTACH THE COMPLETED SF-15 TO
THIS APPLICATION, INCLUDE THE PROOF REQUESTED
ON THE REVERSE SIDE OF THE SF-15. Indicate the type
of 10-point preference you qualify for by marking (X) one of
the following:

City

State

ZIP Code

10-point (disability) pref.

6.

Intersecting streets nearest your home

10-point (compensable disability) pref. – less than 30%
10-point (compensable disability) pref. – 30% or more
10-point (other) pref. (use when you are a spouse,
widow, or mother of a disabled veteran)

7.

E-mail address

8.

Telephone number(s)
Area code
Number

c. Kind of discharge? Mark (X) one box.
Honorable or general under honorable conditions
Mark (X)
one box
(H) (W) (C)

Day

Other – Explain in item 34.

13.

Evening

FOR MALES ONLY: Selective Service – If you are a male
born after December 31, 1959, and you want to be employed by
the federal government, you must be registered with the Selective
Service System. Mark (X) one box.
I certify that I am registered.

Other
phone

I certify that I am not registered. If not, explain in item 34.
A. Raw Scores
Basic Skill Test

D. Regional Office
Mock Interview

E. FIPS State

F. FIPS County

Structured Interview

FOR
OFFICE
B. Converted Scores
C. Final Interview
USE
Score
ONLY
Mock Interview
Structured Interview

H. Final Score with
Veteran’s Preference

I. Language Code

G. Veteran’s
proof

Verified &
Attached
J. Test Date

Page 1

BC-170A, page 3 base copy, solid Black ink

BC-170A, page 3 Overlay, Pantone 280 (20% and 100%)

Section A – APPLICANT PERSONAL DATA – Con.

14a.

17.

Have you ever worked for the Census Bureau?
No

Yes – Indicate dates of employment
and title of position in item 34.

Education – Mark (X) highest education level
Some high school – Did not graduate

18.

High school diploma/GED

Are you now employed by a federal, state, local or
tribal government?
Yes – Indicate name of agency, date hired, and grade level.

Technical degree/Trade school degree or certificate
Associate’s degree
Bachelor’s degree

No

Master’s degree
Doctoral degree

b.

Complete when a Technical/Trade school program,
an Associate’s, Bachelor’s, Master’s or Degree
Year
Doctoral degree is selected in 14a.
(if any) received

19.

Do you receive retirement or have you ever applied for
retirement pay, pension, or other pay based on federal
civilian or District of Columbia government service?

20.

Do any of your relatives work for the Census Bureau?
Include – Father, mother, husband, wife, son, daughter, brother,
sister, uncle, aunt, first cousin, nephew, niece, father-in-law,
mother-in-law, brother-in-law, sister-in-law, son-in-law,
daughter-in-law, stepfather, stepmother, stepson, stepdaughter,
stepbrother, stepsister, half brother, and half sister.

Yes – Explain in item 34.

Name of
institution
City

No

Yes – Provide location (city and state) and position.
State or
country

Section B – RECRUITING SOURCES

15.

How did you hear about census job opportunities?
Mark (X) all that apply.

No

21.

Poster/flyer
Community or organization newsletter/newspaper/leader
Federal, state, tribal employment office/
Job service and information center
Friend or relative working for Census
Toll-free Census number or job line
Census job mailing or postcard
Friend or relative not working for Census

Hiring may be based in part on the hours you are
available to work. Indicate your availability by placing "X" in the
appropriate box(es)
Sun Mon Tues Wed Thurs Fri
Sat
for each day.

a. Any hours
b. Morning

(8 a.m. – 12 noon)

c. Afternoon

(12 noon – 4 p.m.)

d. Evening

(4 p.m. – 9 p.m.)

22.

Total hours per week you are willing to
work up to and including 40 hours.

23.

Some census survey jobs require census employees to conduct the
survey interview by reading and recording responses to questions
in a language other than English. The census employee must also
be able to convince individuals who speak no English to respond to
the interview by explaining the purpose and importance of the
census. Employees will receive Census training, but not
language training.
Are you fluent enough in any specific language other than English,
to hold a conversation, to easily read and record responses, as well
as to respond to questions in that language with individuals who
speak no English? If so, please list the language(s) below and
mark (X) to all that apply.
Speak
Read
Write
Language(s)

Job Fair
Newspaper – advertisement
Newspaper – article

Section D – LANGUAGES

Radio
Internet/E-Mail
School or college
TV
Other – Specify

Section C – OTHER CONSIDERATION

16a.

Are you willing to work in the field? Field work includes
positions primarily outside the office environment and may require
you to travel to all types of neighborhoods to collect personal
information from households.
Yes

b.

your use – Mark (X) all that apply.
Automobile
4-Wheel drive

No

Airplane
Boat
ATV (All terrain
vehicle)

No

Do you have an analog land line telephone?
Yes

e.

24a. Indicate the type(s) of transportation available for

Will you be available to attend a 3–5 day training
session locally or in a different city?
Yes

d.

Section E – TRANSPORTATION

Are you willing to work in the office? (Limited number of
these jobs available.)
Yes

c.

No

Other – Describe
None

No

Do you have computer or data entry experience?
Yes

b. Do you have a valid U.S. driver’s license?

No

FORM BC-170A (6-23-2011)

BC-170A, page 4 base copy, solid Black ink

Yes

No

Page 2

BC-170A, page 4 Overlay, Pantone 280 (20% and 100%)

28a. Name of your next most recent employer

Section F – PRIOR WORK EXPERIENCE

25.
26.

If you have never worked, mark (X) here
and SKIP to item 29.
May we contact your most recent employer?
Yes
No

b.

27a. Name of your present or most recent employer

Supervisor’s name (Last name, first name, middle initial)
Last Name

First Name

b.

MI

Supervisor’s name (Last name, first name, middle initial)
Last Name

c. Address of next most recent employer
MI

First Name

c. Address of your present or most recent employer
City

State

ZIP Code

City

d. Telephone number
State

ZIP Code

Area code

Number

d. Telephone number
Area code

e. Date of employment

Number

Month

Day

Month

Day

Year

e. Date of employment
Month

Day

TO

Year

Year

TO
Month

Day

Year

f. Title of position

f. Title of position
g.
g.

.

$

Salary

.

$
Hourly

Salary

Weekly

Hourly
Monthly

h. Did you supervise?

Yearly

Weekly

Monthly

Yearly

h. Did you supervise?
Yes

Yes

No

No

i.

Describe job duties in detail

i.

Describe job duties in detail

j.

Reason for leaving

j.

Reason for leaving

FORM BC-170A (6-23-2011)

BC-170A, page 5 base copy, solid Black ink

Page 3

BC-170A, page 5 Overlay, Pantone 280 (20% and 100%)

Section G – BACKGROUND INFORMATION
Answer all questions in items 29 through 33 below. Read each statement carefully before responding.
When answering questions 29 through 33 you may omit: 1) traffic fines of $300 or less; 2) any violation of law
committed before your 16th birthday, 3) any violation of law committed before your 18th birthday, if finally decided in juvenile court
or under a Youth Offender law; 4) any conviction set aside under the Federal Youth Corrections Act or similar state law; 5) any
other conviction for which the record was expunged under federal or state law. NOTE: You must include convictions resulting from
a plea of nolo contendere (no contest).
Important note about questions 29 through 32. We will consider the date, facts, and circumstances of each event you
list. In most cases you can still be considered for federal jobs. However, if you fail to tell the truth or fail to list all relevant events,
this failure may be grounds for not hiring you, for firing you after you begin work, or for criminal prosecution [18 U.S.C. 1001].

29. During the last 10 years, have you been convicted, been imprisoned, been on probation, or been on

Mark (X) one

parole? (Includes felonies, firearms or explosive violations, misdemeanors, and all other offenses.) If "YES" use item 34
to provide the date, explanation of the violation, place of occurrence and the name and address of the police department
or court involved. (A felony is defined as any violation of law punishable by imprisonment of longer than one year, except
for violations called misdemeanors under state law which are pubishable by imprisonment of two years of less.)

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

30. Have you been convicted by a military court-martial in the past 10 years? If no military service, answer

"NO." If "YES" use item 34 to provide the date, explanation of the violation, place of occurrence, and the name
and address of the military authority or court involved.

31. Are you now under charges for any violation of law? If "YES" use item 34 to provide the date, explanation of the
violation, place of occurrence, and the name and address of the police department or court involved.

32. During the past 5 years, have you been fired from any job for any reason, did you quit after being told that
you would be fired, or did you leave any job by mutual agreement because of specific problems, or were you
debarred from federal employment by the Office of Personnel Management or any other federal agency?
If "YES," use 34 (below) to write for each job a) the name of the employer; b) the approximate date you left the job,
and c) an explanation of the problem and the reason for leaving.

33. Are you delinquent on any federal debt? (Include delinquencies arising from federal taxes, loans, overpayment of

benefits, and other debts to the U.S. Government plus defaults on federally guaranteed or insured loans such as student
and home mortgage loans.) If "YES", use item 34 to provide the type, length, and amount of the delinquency or default,
and steps that you are taking to correct the error or repay the debt.

34.

EXPLANATIONS OR ANSWERS TO ITEMS 1 THROUGH 33 – Attach additional listing if needed.

Section H – PRIVACY ACT STATEMENT
Solicitation of this information is authorized by section 23 of title 13, U.S. Code, which authorizes temporary appointments in the
Census Bureau. The information will be used primarily to determine your qualifications for employment and may be used also to
identify you to other sources asked to comment on your qualifications, e.g., educational institutions, former employers, and law
enforcement agencies, or to a court during legal proceedings.
We must have your Social Security Number (SSN) to keep our records straight because other people may have the same name
and birthdate. The SSN has been used to keep records since 1943, when Executive Order 9397 asked agencies to do so. The
furnishing of all the information is voluntary, but failure to provide any part or all of the data requested will result in your receiving no
further consideration for employment.
Public reporting burden for this collection of information is estimated to average 15 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. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: Paperwork Project 0607-0139, U.S. Census Bureau, 4700 Silver Hill Road, Stop
1500, Washington, DC 20233-1500. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0139" as
the subject.
The eight digit OMB control number on the first page of this form confirms our authority to collect this information.

Section I – SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS APPLICATION IN DARK INK. Read the following carefully before you sign. A false
statement on any part of your application may be grounds for not hiring you, or for firing you after you begin
work. Also, you may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001). I understand
that any information I give may be investigated as allowed by law or Presidential order. I consent to the
release of information about my ability and fitness for Federal employment by employers, schools, law
enforcement agencies and other individuals and organizations, to investigators, personnel staffing
specialists, and other authorized employees of the Federal Government. I certify that, to the best of my
knowledge and belief, all of my statements are true, correct, complete, and made in good faith.
Signature

Date signed

Print name
FORM BC-170A (6-23-2011)

BC-170A, page 6 base copy, solid Black ink

Page 4

BC-170A, page 6 Overlay, Pantone 280 (20% and 100%)