BC-170D Census Jobs! (for Decennial Tests and Censuses)

Attachment 3

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

The Census Bureau is an
Equal Opportunity Employer
A UNIQUE OPPORTUNITY: EARN MONEY WHILE YOU
SERVE YOUR COMMUNITY
The U.S. Census Bureau is offering temporary short-term
positions in support of the 2020 Census and related tests. While
working, you will serve your country and make a difference in
your community.

DUTIES
We need local residents for a variety of opportunities, including
interviewing, office administration, field outreach, and
supervision. A number of of these jobs involves dealing with the
public. Most positions require locating addresses and conducting
face-to-face interviews with residents who fail to return their
census questionnaire. This involves visiting respondents in a
variety of residence types, asking questions and recording
responses.
The information you collect is confidential and must
not be disclosed to anyone who has not sworn to
protect Census Bureau information.

TRAINING
If selected, you may be asked to attend a paid training session.
Some positions may require you to complete automated self
studies online as well as classroom training. You will be paid for
hours worked including time spent training.

WHEN YOU WILL WORK
ALL jobs will be short term (several weeks) and temporary. Your
actual work hours per week and length of employment (number
of weeks) are subject to work being available. Jobs in the field
will require you to verify and update the Census Bureau’s
address list and maps and interview households via personal
visit. For field positions, your availability to work when people are
home is critical. Afternoon, evening, and weekend hours are the
most productive times to work. You generally will have flexibility
to choose which hours to work during these productive time
periods.

PAY
Social Security deductions will be taken from your earnings.
Federal, state, and local income taxes, where applicable, also
will be deducted. For field work, you will be reimbursed for
authorized mileage and other expenses incurred while working.

For more information, contact:

HOW CAN YOU QUALIFY FOR CENSUS WORK?
1. Noncitizens will only be considered for census jobs when
there is a language requirement and no qualified citizens are
available. If hired, noncitizens must present documentation
of employment eligibility.
2. You must be 18 years old or older to be hired.
3. You must have a valid Social Security Number.
4. You must have a valid e-mail address.
5. Applicants must take a skills assessment. For some
positions, the assessment may be taken in Spanish along
with an English Proficiency Test.
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 the hiring process.
8. You may not engage in any partisan political activity while on
duty.
9. Your current 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 not all people will be home during the day,
you will have to visit some homes during the evening and on
the weekends. This will usually be no later than 9:00 p.m.
You generally will have flexibility to choose which hours to
work during these productive time periods.
PRIVACY ACT AND BURDEN STATEMENT
Solicitation of your personal information is authorized by Title
13 U.S.C., Section 23, which authorizes temporary
appointments in the U.S. Census Bureau. The collection of
your information is also authorized under 5 U.S.C. 301, 3301,
3302, and Executive Orders 9397, 10566.
The purpose of collecting this information is primarily to
determine your qualifications for employment and may also be
used to identify you to other sources asked to comment on
your qualifications, e.g. educational institutions, former
employers, and enforcement agencies, or to a court during
legal proceedings. Personal information collected includes
your Social Security Number (SSN), name, address, date of
birth, telephone number, etc.
Disclosure of the information provided to us may be shared
with other Census Bureau staff for the work-related purposes
identified in this statement as permitted under the Privacy Act
of 1974 (5 U.S.C. Section 552a). Disclosure of this information
is also subject to the published routine uses as identified in the
Privacy Act System of Record Notice OPM/GOVT-5,
Recruiting, Examining, and Placement Records.
Furnishing this information is voluntary, but failure to provide
any part or all of the data requested will result in you 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, 4600 Silver Hill Road, Room 3K138,
Washington, DC 20233-1500. You may E-mail comments to
[email protected]; use "Paperwork Project 0607-0139"
as the subject.
The eight digit OMB number on the first page of this form
confirms our authority to collect this information.

CONTINUE on reverse side

BC-170D

FORM
(4-25-2016)

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

How do I complete the BC-170D, 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 clearly, 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.
Below are a few explanatory notes for some of the items:
Page 1
Section A – Applicant Personal Data
3. Enter your street address followed by your city, county, state
and zip code. Enter the State postal abbreviation for the state
in which you live, for example, MS for Mississippi.
6. Enter your e-mail address. E-mail is the primary way you will
receive information, should you be offered a position.
7. Enter your contact number(s) in the appropriate fields, and
Mark (X) if Mobile
M – mobile
9a. Enter your Date of Birth. For example, enter July 6, 1952 as
follows:
Month
Day
Year

Page 2
Section B – Application Data
13.

Mark an (X) in the appropriate boxes. Mark (X) in all that
apply. If you mark an (X) in the box for Field Data Collection,
you may be considered for positions in the field, interviewing
household members and/or updating address lists and
maps. These positions include working primarily outside the
office environment.
If you mark an (X) in the box for Field Outreach, you may be
considered for positions that involve outreach to potential
applicants and Census Bureau partners. These positions
include working primarily outside the office environment.
If you mark an (X) in the box for Office, you may be
considered for positions that involve working in an office
environment.
If you mark an (X) in more than one box, you may be
considered for multiple types of positions.

14a. Mark (X) in the "Yes" box if you have supervisory
experience. Otherwise, mark "No."
b. Mark (X) in the "Yes" box if you are interested in a
supervisory position. Otherwise, mark "No."
If you mark "Yes" to item 14b, you may be considered for
supervisory positions.

FORM BC-170D (4-25-2016)

All Applicants Will Be Required To Take a
Skills Assessment. What is the Assessment
like?
The assessment contains questions and items designed to
measure knowledge, skills, and abilities, required to perform a
variety of census jobs. In item 13 of this form you are asked to
indicate the type(s) of work you are interested in. Your
responses to this question will determine the set(s) of
assessment questions you will be asked to respond to. The
time it takes to complete the assessment(s) will depend on the
type(s) of work you are interested in.
The assessment 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.

NOTE – THE ACCURACY OF YOUR STATEMENTS WILL BE VERIFIED.

OMB No. 0607-0139
U.S. DEPARTMENT OF COMMERCE

FORM BC-170D
(4-25-2016)

Economics and Statistics Administration

U.S. CENSUS EMPLOYMENT INQUIRY

U.S. CENSUS BUREAU

Section A – APPLICANT PERSONAL DATA

1.

8.

Social Security Number

Sex Mark (X) one box.
Female

2.

9a.

Legal Name
Last Name

Suffix

First Name

MI

Month

b.

Male

Date of birth
Day

Year

Place of birth
City

3.

Residence (home) address
Street address or RFD number (Include apartment number, if any)
Address line 1

State or country

10a.
Address line 2

Are you a citizen or national of the United States?
Yes – SKIP to 11a.
No – Provide country of citizenship

Address line 3

b.
City

Are you a lawful permanent resident of the United States?
Yes – Specify Alien Registration No./USCIS No.
No

County

11a.
ZIP Code

State

4.

FOR MALES ONLY: 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) in one box.
I certify that I am registered – SKIP to 12a.
I certify that I am not registered. Please complete 11b.

Mailing address (if different from Item 3)
Street address or RFD number (Include apartment number, if any)
Address line 1

b.

Address line 2

Can you provide supporting documentation as to
why you are not registered? Mark (X) one box.
Yes – Please attach documentation
No – Please provide explanation

Address line 3

12.
a.

City

State

Military Service
Do you claim veterans’ preference? Mark (X) in one box.
No preference – SKIP to Item 13.
Yes – Enter period of service
Month Year
Month

ZIP Code

Year

TO

5.

Nearest cross streets to your residence (home) address
Cross Street A

Branch, Rank, Campaign or Expeditionary badge or award.

Cross Street B

b.
6.

E-mail address

7a.Telephone number(s)
Area code

Number

Veterans’ preference categories? Mark (X) one box.
5-point Preference – Attach your DD-214 or other official
discharge papers.
10-point Preference – Veteran with a service-connected
disability. (see Note)

Mark (X) if Mark (X) in
Mobile
only one box
Phone
to receive
text messages
(M)

10-point Derived Preference – Spouse, widow, widower,
or mother of a disabled or deceased veteran. (see Note)
Sole survivorship – Attach your DD-214 or other official
discharge papers.
Note: If you claim 10-point preference, you must complete a Standard
Form 15 (SF-15), which is available on-line or at any Federal Job
Information Center. Submit a completed SF-15 and include the applicable
documentation required (listed on page 2 of the SF-15).

b. Do we have permission to text you on your
mobile phone?*
Yes
No
*Standard data fees and text messaging
rates may apply based on your plan with your
mobile phone carrier.

A. Location Office

FOR
OFFICE
USE
E. Census Block
ONLY

Page 1

B. FIPS
State

C. FIPS
County

D. Census Tract

.
F. Veteran’s proof G. Language code(s)
Verified &
attached

21.

Section B – APPLICATION DATA

13.

Which of the types of work listed below are you interested in?
Mark (X) all that apply.

•
•

14a.

Have you worked for the Federal government or military
and received a Voluntary Separation Incentive Payment
(VSIP) or "Buyout" within the past 5 years?
Buyout laws require that if an employee who received a Buyout is
re-employed with the Federal government within five (5) years of
receiving the Buyout, the Buyout must be paid back in full before the
employee may be hired.

The majority of available jobs involve field data collection.
There are a limited number of field outreach and office jobs.
Field Data Collection – These positions require dealing with the
public and could involve the following tasks: knocking on doors to
collect personal information and verifying household address listings.
Limited field data collection supervisory positions are also available.

I have NOT received a Buyout from a prior Federal appointment
within the past 5 years

Field Outreach – These positions involve outreach to Census partners
and potential applicants for Census jobs. These positions involve working
outside an office environment.

I have received a Buyout from a prior Federal appointment
within the past 5 years. I understand that I must repay the
full Buyout amount before I may be appointed. If paid in full
must provide proof of payment.

Office – These positions could involve the following tasks: file
maintenance, data entry, answering/making phone calls, word processing,
shipping and receiving, processing payroll and personnel actions and other
administrative operations. Limited office supervisory positions are also
available. There are a limited number of Census offices.

Indicate Buyout year

Year

Agency

Do you have supervisory experience?
Yes
No

b.

15.

22.

Are you interested in a supervisory position?
Yes
No

Do any of your relatives currently work for the Census
Bureau? Include – Parents, spouse, children, grandparents, siblings,
(including half), aunts, uncles, first cousins, nephews, nieces, in-laws
and step relatives.
Yes – If yes, indicate relationship, first/last name, location
and current title

Have you ever worked for the Census Bureau?
Yes – Indicate most recent title and dates of employment and
attach most recent SF-50 if available.
No Title
Month

16.

Month

Year

No
Current title

Relationship

Year

To
Are you currently employed by a Federal government agency ?

First Name

Last Name

Yes – Indicate hire date and agency.
No

Month

Year

Agency

City

Hire date

17.

Are you currently employed by a state, local or tribal
government agency?
Yes – Indicate current title and agency
No
Agency
Title

If you have additional information continue in Section G

23.
18.

Are you currently an elected official for any government
agency?
Yes – Indicate current title and agency.
No
Agency
Title

19.

Indicate the hours and days you are available to work
by placing "X" in all appropriate boxes for each day.
Census field work will usually require you to work evenings and
weekends. Some positions will require shift work. Hiring may
be based in part on your availablity.
Sun

a.
b.

Are you currently employed by a law enforcement agency?
Yes – Indicate current title and agency
No
Title

20.

State

Agency

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

Mon

Tues

Any hours
Morning
(8 a.m. – 12 noon)

c.

Afternoon
(12 noon – 4 p.m.)

d.

Evening
(4 p.m. – 9 p.m.)

e.

Shift Work
(8:30 a.m. – 3:30 p.m.)

f.

Shift Work
(3 p.m. – 10 p.m.)

Yes – Indicate the agency and explain in section G.

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

No
FORM BC-170D (4-25-2016)

Page 2

Wed

Thurs

Fri

Sat

27a. Name of your next most recent employer

Section C – PRIOR WORK EXPERIENCE

24.

Have you ever worked?

25.

No – If "No" SKIP to Section D
Yes
May we contact your current employer?

b. Address of next most recent employer

No

Yes

Country

26a. Name of your current or most recent employer

Address line 1

b. Address of your current or most recent employer
Address line 2
Country
Address line 1
Address line 3
Address line 2
City
Address line 3
State

ZIP Code

City

State

c. Supervisor’s name (Last name, first name, middle initial)

ZIP Code

Last Name

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

First Name

First Name

MI

MI

d. Telephone number
Area code

Number

d. Telephone number (Employer)
Area code

Number

e. Dates of employment
Month

Day

Month

Day

Year

e. Dates of employment
Month

Day

Year
TO
Year

TO
Month

Day

Year

f. Title of position
f. Title of position
g.

Average number of hours worked or working per week

g. Average number of hours worked or working per week
h. Salary
h. Salary

.
Hourly

.

$

$
Weekly

Bi-weekly

Hourly
Monthly

Weekly

Bi-weekly

Monthly

Yearly

Yearly

i.

Describe job duties (If more space is needed, continue in Section G)

i.

Describe job duties (If more space is needed, continue in Section G)

j.

Did you supervise other employees?

j.

Did you supervise other employees?

Yes

k.

Yes

FORM BC-170D (4-25-2016)

Yes

No

Are you still employed by this employer?

k.

No – Indicate reason for leaving.

Yes

Page 3

No

Are you still employed by this employer?
No – Indicate reason for leaving.

Section D – LANGUAGE SKILLS

28.

Section E – TRANSPORTATION

Some Census jobs require employees to conduct the Census interview
by reading and recording responses to questions in a language other
than English. The employee must 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 job-related
training, but not language training.
Are you fluent in any language where you can hold a
conversation, read and record responses, and respond to
questions in that language? If so, indicate the language(s) below
and mark (X) all that apply.
Fluent
Language(s)
Dialect
Speak Read Write

29a. Indicate the type(s) of transportation available for your use –
Mark (X) ALL that apply.
Automobile
Check if 4-Wheel Drive

ATV (All terrain vehicle)
Other – Describe

Airplane
Boat
None

b.

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

No

Please include American Sign Language.
If you need to add additional languages continue in section G.

Section F – SURVEY DATA (VOLUNTARY)
EDUCATION
Mark (X) highest education level.
Some high school – Did not graduate
High school diploma/GED

Some college –
Did not graduate

Technical degree/Trade school
degree or certificate

Associate’s degree

Master’s degree
Doctoral degree

Bachelor’s degree

RECRUITING SOURCES
How did you hear about census job opportunities? Mark (X) one box only.
Community or organization leader or newsletter

Toll-free Census phone number/jobs line

Newspaper – advertisement

Federal, state, tribal employment office/Job
service and information center

Census job mailing/postcard

Newspaper – article

Census Recruiter
Census Jobs Website
Internet advertisement
Social Media

Friend or relative working for Census

Radio

Friend or relative not working for Census

School or college

Brochure/poster/flyer

TV advertisement or news

Job Fair

Other – Specify

Section G – ADDITIONAL INFORMATION (Please list item number)

Section H – 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-170D (4-25-2016)

Page 4