Applicant Background Questionnaire printable pdf download

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond

assist the agency in evaluating and improving its efforts to publicize job openings and to

to a collection of information unless it displays a valid OMB control number. The

encourage employment applications from a diverse group of qualified candidates. The

valid OMB control number for this information is 2105-0557.

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

The public reporting burden for this collection of information is estimated to average 4

will then assess the effectiveness of specific outreach efforts and means of communicating

minutes per response, including the time for reviewing instructions, searching existing

information on job vacancies in light of this information. Personal identifying information will

data sources, gathering and maintaining the data needed, and completing and reviewing

not be included in the tabulation of data.

the collection of information. Send comments regarding this burden estimate or any

other aspect of this collection of information, including suggestions for reducing this

The completion of this form is voluntary. This information will have no effect on the

burden to the U.S. Department of Transportation, Departmental Human Resources

processing of your application or hiring decisions.

Office, 400 7th St, SW., Washington, DC 20590; and the Office of Management and

Budget, Paperwork Reduction Project, Washington, D.C. 20503.

PRIVACY ACT INFORMATION: This information is provided pursuant to Public Law 93-

579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal records and

Solicitation of this information is in accordance with “Federal Equal Opportunity

forms that solicit personal information. Authority: Section 7201 of title 5 of the U.S. Code

Recruitment Program” (FEORP), found in part 720 of title 5, Code of Federal

and Section e-16 of title 42 of the U.S. Code

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:

__ American Indian or Alaska Native

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.

__ 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, Philippine Islands, Thailand, and Vietnam.

__ Black or African American

A person having origins in any of the black racial groups of Africa.

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or

__ Native Hawaiian or other Pacific Islander

other Pacific Islands.

__ White

A person having origins in any of the original peoples of Europe, the Middle East, or

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

( )

____ 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

Applicant Background Questionnaire

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