OMB Control No.: 1091-0001
Expiration Date: 03/31/2006

U.S. DEPARTMENT OF THE INTERIOR

APPLICANT BACKGROUND SURVEY

GENERAL INSTRUCTIONS

In boxes 1 to 3, please print using capital letters only. Read each item thoroughly before circling the appropriate codes in boxes 4 and 5. Enclose this form with your application package or mail it directly to the same address.

YOUR PRIVACY IS PROTECTED

This information is needed to determine if our recruitment efforts are reaching all segments of the country, as required by Federal law. This is vital information not available from any other source. We can only get it directly from you.

Your voluntary responses are treated in a highly confidential manner. They are not released to the panel rating the applications, to the selecting official, to anyone else who can affect your application, or to the public. This form will be destroyed after the position is filled.

The only information associated with your name in our computer system is whether you have returned the completed form, so that we may follow up if no response has been received. Your responses are stored as a tally for the group of all applicants for this vacancy in a manner that cannot be associated with any individual application. No information taken from this form is ever placed in a Personnel file or Personnel data base.

Thank you for helping us provide better service.

1. Vacancy Announcement No.:

2. Position Title:

3. Name (Last, First, MI):

4. How did you learn about this position? (Circle up to three codes).

01– Private information service
02 – Magazine
03 – Newspaper
04 – Radio
05 – TV
06 – Poster
07 – Private Employment Office
08 – State Employment Office (Unemployment Office)

09 – Agency Personnel Department (bulletin board or other announcement)
10 – Agency or other Federal government recruitment at school or college
11 – Federal, state, or local Job Information Center
12 – Religious organization
13 – School or college counselor or other official
14 – Friend or relative working for this agency
15 – Friend or relative not working for this agency
16 – Internet or World Wide Web
17 – Other (Specify) __________________________________

5. Identify yourself in each category: (Circle the appropriate codes)

 

Ethnicity:

D – Hispanic or Latino

N – Not Hispanic or Latino

Race (circle one or more)

 A  –  American Indian or Alaska Native
    B  –  Asian
      C  –  Black or African American
         G  –  Native Hawaiian or Other Pacific Islander
            E  –  White

Sex:

M – Male

F – Female

 

 

Do you have any physical disabilities?

Y - Yes                N - No

 

If yes, do you have a targeted* disability?       Y - Yes             N - No

* The Equal Employment Opportunity Commission targets the following disabilities for extra recruitment efforts: Deaf, Blind, Missing Extremities, Partial/Complete Paralysis, Convulsive Disorders, Mentally Retarded, Mental Illness or Distortion Limb/Spine.

 

SEE BACK OF THIS FORM FOR THE PRIVACY ACT STATEMENT,

PUBLIC BURDEN STATEMENT AND THE PAPERWORK REDUCTION ACT STATEMENT

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PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq.) requires us to inform you that this information is being collected for planning and assessing affirmative employment program initiatives.  Response to this request is voluntary.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number.

The estimated burden of completing this form is 5 minutes per response, including the time for reviewing instructions.  Direct comments regarding the burden estimate or any other aspect of this form to the U.S. Department of the Interior, Director for Equal Opportunity, 1849 C Street, NW, MS-5221 MIB, Washington, DC 20240.

 

PRIVACY ACT STATEMENT

GENERAL:  This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), for individuals completing Federal records and forms that solicit personal information.

AUTHORITY:  Sections 1302, 3301, 3304, and 7201 of Title 5 of the U.S. Code.

PURPOSE AND ROUTINE USES:  The form will only be seen by DOI Personnel and Equal Employment Opportunity officials. Data summarizing all applicants for a position will be used to determine if we are effectively recruiting from all portions of the country, in conformance with the requirements of Federal law.  Only summary data is reported, and only in a format which can not be broken out by individual applicants.  No individual data is ever provided to selecting officials.

EFFECTS OF NONDISCLOSURE:  Providing this information is voluntary.  No individual personnel selections are made based on this information.

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