Form FR 28s FR 28s Applicant's Voluntary Self-Identification Form

July 7, 2014 - DRAFT

Applicant's Voluntary

_{Self-Identification Form}

Board of Governors

of the Federal Reserve System

OMB No. 7100-0181

Average hours per response 1 minute

Approval expires February 28, 2011

The Board of Governors of the Federal Reserve System (Board) is requesting that you furnish this information under the authority of 42 U.S.C. 2000e-16, which requires that Federal employment practices be free of discrimination and provide equal employment opportunity for all. Your providing of this information is strictly voluntary. Your failure to do so will have no effect on the decision to hire you or on your employment with the Board. The information you provide on this form

will be kept in a confidential file separate from your application for employment and will not be shared with the selecting

official or other persons who will make the hiring decision.

GENDER

_{Female Male}

Please respond to the ethnicity question and race identification below.

ETHNIC SELF IDENTIFICATION

Are you Hispanic or Latino? Yes No If yes, please select from the following: Cuban South or Central American Mexican Other Spanish Culture

Puerto Rican

RACE SELF-IDENTIFICATION (Mark one or more)

American Indian or Alaskan Native

A person having origins in any of the original peoples of North and 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, and 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.

PRIVACY ACT STATEMENT

Collection of this information is authorized by sections 10 and 11 of the Federal Reserve Act (12 U.S.C. §§ 244 & 248), 42 U.S.C. § 2000e-16, and 12 CFR part 268. The information will be used in planning and monitoring equal employment opportunity programs at the Board, including preparing statistical reports regarding race, gender and national origin of applicants. Providing this information is voluntary and failure to provide the information will have no effect on your application. Disclosure of the information may be made for enforcement, statutory, or regulatoary purposes; to another agency or Federal Reserve Bank; to the Equal Employment Opportunity Commission; to another federal agency, a court or a party in litigation, when the Board or the United States is a party to the litigation; in response to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a pending judicial or administrative proceeding; to contractors, grantees or volunteers performing work on a contract, service, grant, cooperative agreement or job for the Board; to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of the

individual; and in accordance with any other routine uses of the records specified in the Board’s system of records notice

_{“FRB-General Personnel RecordsRecruiting and Placement Records,,” 68 73 Federal Register 22,38124984.}

_{Name (Last, First, Middle Initial) Signature Date}

_{Title, Grade, Announcement Number of Position for which you are applying}

FR 28s (03/08)