Free U - Federal

OMB No. 2105-0557 Expiration: 08/31/2009

U.S. DEPARTMENT OF TRANSPORTATION

APPLICANT BACKGROUND QUESTIONNAIRE
The U.S. Department of Transportation requests that you voluntarily complete this form to assist the agency in evaluating and improving its efforts to publicize job openings and to encourage employment applications from a diverse group of qualified candidates. The Department will use the data you supply to determine how many applicants are from different groups and how many of these applicants are qualified for the job in question. The Department will then assess the effectiveness of specific outreach efforts and means of communicating information on job vacancies in light of this information. Personal identifying information will not be included in the tabulation of data. The completion of this form is voluntary. This information will have no effect on the processing of your application or hiring decisions. PRIVACY ACT INFORMATION: This information is provided pursuant to Public Law 93579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal records and forms that solicit personal information. Authority: Section 7201 of title 5 of the U.S. Code and Section e-16 of title 42 of the U.S. Code According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 2105-0557. The public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Transportation, Departmental Human Resources Office, 400 7th St, SW., Washington, DC 20590; and the Office of Management and Budget, Paperwork Reduction Project, Washington, D.C. 20503. Solicitation of this information is in accordance with "Federal Equal Opportunity Recruitment Program" (FEORP), found in part 720 of title 5, Code of Federal Regulations.

PLEASE COMPLETE THE FOLLOWING: Name:

Sex:

__ Male

__ Female

Title, Grade, and Announcement Number of position for which you are applying:

Do you have a disability?

___ Yes

___ No

If yes, please provide information on your disability by selecting the appropriate category: __ I do not choose to identify my disability __ Complete paralysis __ Total Deafness __ Convulsive disorder __ Blind/uncorrectable visual impairment __ Mental retardation __ Missing extremity(ies) __ Mental or emotional illness __ Partial paralysis __ Severe distortion of limbs or spine __ I have a disability but it is not listed Are you of Hispanic or Latino origin? __ Yes ___ No Please select one or more racial categories:
A person having origins in any of the original peoples of North and South America (including Central America), and who maintains cultural identification through tribal affiliation or community attachment. A person having origins in any of the original peoples of the Far East, Southeast Asia, __ Asian or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and Vietnam. A person having origins in any of the black racial groups of Africa. __ Black or African American A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or __ Native Hawaiian or other Pacific Islander other Pacific Islands. A person having origins in any of the original peoples of Europe, the Middle East, or __ White North Africa. How did you find out about this vacancy? (Select all that apply) ____ 8. Friend or Relative Working for DOT ____ 1. Magazine/Newspaper ____ 9. Friend or Relative Not Working for DOT ____ 2. Radio/Television Broadcast ____10. DOT's Careers in Motion Web Site ____ 3. DOT Human Resources Office (www.careers.dot.gov) ____ 4. State Employment Office ____ 11. Internet or Other Web Site ____ 5. Government Recruitment at School ____ 12. State Vocational Rehabilitation Agency or ____ 6. Attendance at Conference, Meeting, or Job U.S. Dept. of Veterans' Affairs Fair (specify _______________________) ____ 13. Other (specify _____________________) ____ 7. Federal, State, or Local Job Information Center

__ American Indian or Alaska Native