Fillable Applicant Survey not affect your chance for employment. (ILW.COM)

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Applicant Survey not affect your chance for employment. (ILW.COM)

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YES NO
Your response to this survey is voluntary. Please read each section thoroughly and answer each question to
the best of your ability. Place the applicable number for each section in the box provided.
SECTION A. RACE/ETHNICITY
1.
A. Mexican
D. Central American
B. Puerto Rican
E. South American
F. Other
C. Cuban
See Reverse for Disability and Sex Status information
OMB No. 1115-0188
Applicant Survey
PURPOSE AND ROUTINE USES
PRIVACY ACT INFORMATION
This information is used to evaluate the agency's
recruitment of minorities, women and persons with
disabilities and to help ensure that agency personnel
practices meet the requirements of Federal Law.
EFFECTS OF NONDISCLOSURE
Providing this information is voluntary. No individual
personnel selections are made based on this
information. Failure to provide this information will
not affect your chance for employment.
Vacancy Announcement No. Position, Title, Series, Grade Duty Location
Name (Last, First, MI) (Please print)
Year of Birth Social Security No.
Are you a Veteran? (A person who was separated with an honorable discharge or under honorable conditions
from active duty in the armed forces performed for more than 180 consecutive days, other than for training.)
INFORMATION ON RACE/ETHNICITY, SEX AND DISABILITY STATUS
2.
3.
4.
Form G-942 (Rev. 10/17/00)Y
Information Regarding Disclosure of Your Social
Security Number Under Public Law 93-579, Section
7(b)
- Solicitation of your Social Security Number is
authorized under Executive Order 9397 dated
November 22, 1942. Only authorized agency
officials will have access to your Social Security
Number.
American Indian or Alaskan Native - A person
having origin in any of the original peoples of North
America and who maintains cultural identification
through community recognition or tribal affiliation.
Asian or Pacific Islander - A person having origins
in any of the original peoples of the Far East,
Southeast Asia, and Indian subcontinent, or the
Pacific islands (for example, China, India, Japan,
Korea, the Philippines, Samoa, Vietnam).
White, Not of Hispanic Origin - A person having
origins in any of the original peoples of Europe,
North Africa, or the Middle East. Does not
include persons of Mexican, Puerto Rican,
Cuban, Central or South American cultures or
origins. (See Hispanic). Also includes persons
not in other categories.
Hispanic - A person of Mexican, Puerto Rican,
Cuban, Central or South American, or other
Spanish cultures or origins. Does not include
persons of Portuguese culture or origin. (Please
indicate "X" in appropriate box below and place
a "5" in the box for Section A above.)
- Section 1302, 3301, 3304, 7201 of
Title 5 of the U.S.C., 42 U.S.C. Section 2000e and
29 U.S.C. Section 791.
Authority
- This information is provided pursuant to
Public Law 93-579 (Privacy Act of 1974), December
31, 1974, for individuals completing Federal records
and forms that solicit personal information.
General
5.
Black or African American, Not of Hispanic Origin
- a person having origins in any of the black racial
groups of Africa. Does not include persons of
Mexican, Puerto Rican, Cuban, Central or South
American or other Spanish cultures or origins
(See Hispanic).
U.S. Department of Justice
Immigration and Naturalization Service
2. Female
1. Male
A person is disabled if he or she has a physical or mental impairment which substantially limits one or more
major life activities. If you have more than one disability, choose the one which results in the most substantial
limitation.
05. I do not have a disability.
K. Federal Research Service
A. Friend in INS
F. DOJ Career Opportunities
B. Friend not in INS
L. U.S. Employment ServiceG. Office of Personnel Managment
C. Agency Personnel Office
H. College or University
M. Newspaper
N. Television
I. Radio
E. Another Federal Agency J. Military Installation
Paperwork Reduction Act Notice.
An agency may not conduct or sponsor an information collection and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be
easily understood and which impose the least possible burden on you to provide us with infommation. Often this is difficult because some
Immigration laws are very complex. The estimated average time to complete and file this application is 4 minutes per application. If you have
comment regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization
Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536; OMB No. 1115-0188.
DO NOT MAIL YOUR COMPLETED APPLICATION
TO THIS ADDRESS.
SECTION B. SEX
SECTION C. DISABILITY STATUS
06. Handicap not listed.
23. Inability to read ordinary size print, not correctable by glasses (can read oversize print or use assiting device).
25. Blind in both eyes (no usable vision, may have some light perception).
28. Missing one arm.
33. Missing both hands or arm and one foot or leg.
64. Partial paralysis of both hands.
65. Partial paralysis of both legs, any part.
67. Partial paralysis of one side of the body, including one arm and one leg.
68. Partial paralysis of three or more major parts of the body (arms and legs).
71. Complete paralysis of both hands.
72. Complete paralysis of one arm.
75. Complete paralysis of legs.
77. Complete paralysis of one side of body, including one arm and one leg.
78. Complete paralysis of three or more major parts (arms and legs).
81. Heart disease with restriction or limitation of activity.
82. Convulsive disorder (e.g. epilepsy).
86. Pulmonary or respiratory disorders (e.g., tuberculosis, emphysema, asthma).
90. Mental retardation (a chronic and lifelong condition involving a limited ability to learn, to be educated,
and to be trained for useful productive employment as certified by a state vocational rehabilitation
agency).
91. Mental or emotional illness (a history of treatment for mental or emotional problems).
92. Severe distortion of limbs and/or spine (e.g. dwarfism, severe distortion of the back).
SECTION D. ELIGIBILITY UNDER SPECIAL HIRING AUTHORITY
SECTION E. RECRUITMENT INFORMATION
If you have been certified by a state vocational rehabilitation agency or the Veterans Administration as eligible
for appointment to a Federal position under a special appointing authority (Schedule A or B) because you are
severely, physically or mentally disabled, please attach the certification to your application so that you may be
given full consideration under the special appointing authority.
D. Vacancy Announcement
16. Total deafness in both ears, with or without understandable speech.
35. Missing one hand or arm and one foot or leg.
HOW DID YOU HEAR ABOUT THE POSITION FOR WHICH YOU ARE APPLYING? (Check all boxes
which apply).
Form G-942 (Rev. 10/17/00)Y Page 2
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Completed 9 January 2021

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