FR 28s

DRAFT

Applicant’s Voluntary Self-Identification
Board of Governors
of the Federal Reserve System
Washington, DC 20551

OMB No: 7100-0181
Approval expires October 31, 2017
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An equal opportunity employer

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. Sections 10 and 11(l) of the Federal Reserve Act (12 U.S.C. §§ 244 and
248(l)). 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 confidentialand
will not be shared with the selecting officialorotherpersonswhowillmakethehiringdecision.
Name:

Gender:

Female

Male

I do not wish to disclose

Last, First, Middle Initial

Position for which you are applying
Title

Grade

Announcement Number

Ethinicity Self-Identification
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

I do not wish to disclose

(Note: If you have checked this box, you have completed this
form and do not need to complete the Race Self-Identification
section below.)

Race Self-Identification (select 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.
I do not wish to disclose

Privacy Act Statement: The information you provide is being collected to assist the Board in carrying out its responsibilities under the Rehabilitation Act of 1973, Title
VII of the Civil Rights Act, and other nondiscrimination statutes. The information collected is used in planning and monitoring equal employment opportunity programs
at the Board, including preparing statistical reports regarding race, gender, and national origin. This collection is authorized by Sections 10 and 11 of the Federal Reserve Act (12 U.S.C. § 244 and 248(l)). Providing this information is voluntary and failure to provide the information will not have effect on your application. The information you provide will be stored in the system of records entitled BGRS-1 “FRB—Recruiting and Placement Records and “BGFRS-24: FRB—EEO General Files.”
All or part of the information may be disclosed outside of the Board in accordance with the routine uses A, B, C, D, E, F, G, H, and I (see Attachment). In addition, all or
part of the information may also be disclosed outside of the Board in order: (1) to disclose information to management as a data source for production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related personnel management functions
or manpower studies and may also be utilized to respond to investigative or legal requests for statistical information (without personal identification of individuals),
and (2) to disclose information to any source from which additional information is requested (to the extent necessary to identify the individual, inform the source of the
purpose(s) of the request, and identify the type of information requested), when necessary to obtain information relevant to a Board decision to hire or retain an employee, issue a security clearance, conduct a security or suitability investigation of an individual, classify jobs, let a contract, or issue a license, grant, or other benefit.
Paperwork Reduction Notice: The estimated average reporting burden for this information collection is 1 minute per response, including the time to gather the
information in the required form and to review instructions and complete the form. A federal agency may not conduct or sponsor, and an organization (or a person)
is not required to respond to a collection of information, unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this employment application, including suggestions for reducing this burden, to Secretary, Board of Governors of the Federal Reserve System,
20th and C Streets, NW, Washington, DC 20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100-0181), Washington, DC 20503.

Signature:

Date:
MM/DD/YYYY

FR 28S

11/2016

DRAFT
Applicant’s Voluntary Self-Identification–(Continued)
Board of Governors of the Federal Reserve System

General Routine Uses of Board Systems of Records
A. Disclosure for Enforcement, Statutory and Regulatory Purposes.
Information may be disclosed to the appropriate federal, state,
local, foreign, or self-regulatory organization or agency responsible for investigating, prosecuting, enforcing, implementing, issuing, or carrying out a statute, rule, regulation, order, policy, or
license if the information may be relevant to a potential violation
of civil or criminal law, rule, regulation, order, policy or license.
B. Disclosure to Another Agency or a Federal Reserve Bank.
Information may be disclosed to a federal agency in the executive, legislative, or judicial branch of government, or to a Federal Reserve Bank, in connection with the hiring, retaining, or
assigning of an employee, the issuance of a security clearance,
the conducting of a security or suitability investigation of an individual, the classifying of jobs, the letting of a contract, the issuance of a license, grant, or other benefits by the receiving entity,
or the lawful statutory, administrative, or investigative purpose of
the receiving entity to the extent that the information is relevant
and necessary to the receiving entity’s decision on the matter.
C. Disclosure to a Member of Congress. Information may be disclosed to a congressional office in response to an inquiry from
the congressional office made at the request of the individual to
whom the record pertains.
D. Disclosure to the Department of Justice, a Court, an Adjudicative
Body or Administrative Tribunal, or a Party in Litigation. Information may be disclosed to the Department of Justice, a court, an
adjudicative body or administrative tribunal, a party in litigation,
or a witness if the Board (or in the case of an OIG system, the
OIG) determines, in its sole discretion, that the information is
relevant and necessary to the matter.
E. Disclosure to Federal, State, Local, and Professional Licensing
Boards. Information may be disclosed to federal, state, local,
foreign, and professional licensing boards, including a bar
association, a Board of Medical Examiners, a state board of accountancy, or a similar governmental or non-government entity

FR 28S

that maintains records concerning the issuance, retention, or
revocation of licenses, certifications, or registrations relevant to
practicing an occupation, profession, or specialty.
F. Disclosure to the EEOC, MSPB, OGE and OSC. Information
F.
may be disclosed to the Equal Employment Opportunity Commission, the Merit Systems Protection Board, the Office of Government Ethics, or the Office of Special Counsel to the extent
determined to be relevant and necessary to carrying out their
authorized functions.
G. Disclosure to Contractors, Agents, and Others. Information may
be disclosed to contractors, agents, or others performing work
on a contract, service, cooperative agreement, job, or other activity for the Board and who have a need to access the information in the performance of their duties or activities for the Board.
H. Disclosure to Labor Relations Panels. Information may be disclosed to the Federal Reserve Board Labor Relations Panel or
the Federal Reserve Banks Labor Relations Panel in connection
with the investigation and resolution of allegations of unfair labor
practices or other matters within the jurisdiction of the relevant
panel when requested.
I.I. Disclosure Where Security or Confidentiality Has Been Compromised. Information may be disclosed when (1) it is suspected or
confirmed that the security or confidentiality of information in the
system of records has been compromised; (2) the Board has
determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests,
identity theft or fraud, or harm to the security or integrity of this
system or other systems or programs (whether maintained by
the Board or another agency or entity) that rely upon the compromised information; and (3) the disclosure is made to such
agencies, entities, and persons who are reasonably necessary
to assist in connection with the Board’s efforts to respond to the
suspected or confirmed compromise and prevent, minimize, or
remedy such harm.

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11/2016