OMB Number  0990-0208

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Applicant Background Survey


This survey is used to collect and analyze data involving race, sex, age, disability, and national origin from applicants for employment.  The information you provide will be used for statistical purposes only and will not in any way affect you individually.  While completion of this form is voluntary, your cooperation is important to help ensure accurate information regarding employment practices.  We ask you to answer each of the questions to the best of your ability.  Print your answers clearly.   Read each item thoroughly before selecting the appropriate response.


A.  Announcement Number(s) and/or position(s) for which you are applying.


B.  Year of Birth  __________          C.   For Agency Use


D.  How did you learn about the position or exam for which you are applying?  For example:  radio, job fair, friend, newspaper, school counselor, etc.


E. Ethnicity

_____ HISPANIC or LATINO - a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless or race.

_____ NOT HISPANIC or LATINO


F.  Race (select one or more)

_____ AMERICAN INDIAN or ALASKA NATIVE - a person having origins in any of the original peoples of North or 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 Phillipine Islands, Thailand, or 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 America.


G.  Sex

_____ Male    _____ Female


H.  Disability

A person is disabled if he or she has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment.

_____ I do not have a disability  _____ Convulsive disorder

_____ Deaf                        _____ Mental retardation

_____ Blind                       _____ Mental or emotional illness

_____ Missing extremities         _____ Severe distortion of limbs and/or spine

_____ Partial paralysis           _____ Complete paralysis

_____ I have a disability, but it is not listed (specify):__________________                                                            


PRIVACY ACT AND PAPERWORK REDUCTION STATEMENT

Privacy Act Information:  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.  The authority in Title V of the U.S. Code, sections 1320, 3301, 3304, and 7201.  - Purpose and Routine Uses: This form is maintained in Privacy Act system records 09-90-0006, Applicants for Employment Records, HHS/OS/ASMB.  The information in this survey is used solely for research and for statistical purposes to help ensure that agency personnel practices meet the requirements of the law.  No other uses will be made of this information.   This form will be separated from the other application materials upon receipt. - Effects of Non-Disclosure:  Providing this information is voluntary; no individual personnel selections are made based on this information.    Paperwork Reduction Act Statenment:  A Federal agency may not conduct or sponsor, and  a person is not required to respond to, a collection of information unless it displays a current valid OMB control number.  Public reporting burden for this collection of information is estiamted to vary from one to three minutes with an average of two minutes per response, including time for reviewing instructions and completing and reviewing the collection of information.