Application - New Equity Demographics Questions

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control Number: 1660-0154
Expires: 07/31/2025

EQUITY DEMOGRAPHICS QUESTIONS
PAPERWORK BURDEN DISCLOSURE NOTICE:
Public reporting burden for this data collection is estimated to average 5 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of
information is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form.
Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100,
Paperwork Reduction Project (1660-0154) NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT
AUTHORITY: FEMA collects, uses, maintains, retrieves, analyzes, and disseminates the records within this system under the authority of the Robert
T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act), Section 308 Nondiscrimination in Disaster Assistance.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of analyzing demographic data to determine if any inequities
exist in the distribution of disaster assistance and to assess changes to policies and procedures to better assist underserved communities if such
inequities are found.
ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance
files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. FEMA may share the personal
information of non-citizens, as permitted by the following Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Improvement Plan (DAIP)
(Nov. 16, 2021); DHS/FEMA/PIA-027 National Emergency Management Information System –Individual Assistance (NEMIS-IA) Web-based and
Client-based Modules (June 29, 2012): DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014).
VOLUNTARY RESPONSE: Providing responses to the demographic questions is voluntary. There are no consequences for not providing the
information. Failure to provide demographic data will not affect your potential eligibility for disaster assistance.
Please complete the following voluntary demographic questions. The responses provided to the below questions will not be used for adjudicating the
individual's application and will have no impact on your potential benefits.:

DRAFT

1. Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race)
Yes

No

Prefer Not to Answer

2. Please select the racial category or categories that you most closely identify with. Select as many as apply.
American Indian or Alaska Native
Asian
Black or African American

Native Hawaiian and Other Pacific Islander
White
Prefer not to answer

3. Are you an enrolled member of a Tribal Nation?
Yes

No

Prefer Not to Answer

If so, which Tribal Nation are you a member of?
4. Is your gender…
Female
Male

Another Identify (e.g. non-binary or gender non-conforming)
Prefer not to answer

5. Which of the following best describes your highest level of formal education?
Did not complete high school
High school graduate / GED
Some college
Associate degree

Bachelor’s degree
Master’s degree (or Graduate degree to include Master’s and professional)
Doctoral degree
Prefer not to answer

6. Is your marital status…
Never married
Married or living with partner
Separated

FEMA Form FF-256-FY-21-100 (7/22)

Widowed
Divorced
Prefer not to answer

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