+------------------------------+---+---+------------------------------------+
| OMB Control No.: 1091-0001   |   |   |                                    |
|                              |   |   |                                    |
| Expiration Date: 04/30/2009  |   |   |                                    |
|                              |   |   |                                    |
| **U.S. DEPARTMENT OF THE     |   |   |                                    |
| INTERIOR**                   |   |   |                                    |
|                              |   |   |                                    |
| **APPLICANT BACKGROUND       |   |   |                                    |
| SURVEY**                     |   |   |                                    |
+------------------------------+---+---+------------------------------------+
| **GENERAL INSTRUCTIONS**     |   |   | **YOUR PRIVACY IS PROTECTED**      |
|                              |   |   |                                    |
| **In boxes 1 to 3, please    |   |   | **This information is needed to    |
| print using capital letters  |   |   | determine if our recruitment       |
| only. Read each item         |   |   | efforts are reaching all segments  |
| thoroughly before circling   |   |   | of the country, as required by     |
| the appropriate codes in     |   |   | Federal law. This is vital         |
| boxes 4 and 5. Enclose this  |   |   | information not available from any |
| form with your application   |   |   | other source. We can only get it   |
| package or mail it directly  |   |   | directly from you.**               |
| to the same address.**       |   |   |                                    |
|                              |   |   | **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 to      |
|                              |   |   | 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**\          | 0 |   |                                    |
| **03 -- Newspaper**\         | 9 |   |                                    |
| **04 -- Radio**\             | - |   |                                    |
| **05 -- TV**\                | - |   |                                    |
| **06 -- Poster**\            | A |   |                                    |
| **07 -- Private Employment   | g |   |                                    |
| Office**\                    | e |   |                                    |
| **08 -- State Employment     | n |   |                                    |
| Office (Unemployment         | c |   |                                    |
| Office)**                    | y |   |                                    |
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|                              | _ |   |                                    |
|                              | * |   |                                    |
|                              | * |   |                                    |
+------------------------------+---+---+------------------------------------+
| **5. Identify yourself in    |   |   |                                    |
| each category: (Circle the   |   |   |                                    |
| appropriate codes.)**        |   |   |                                    |
+------------------------------+---+---+------------------------------------+
|                              |   |   |                                    |
+------------------------------+---+---+------------------------------------+

+-------------+-----------------------------------------+--------------+
| **E         | **Race** **(circle one or more)**       | **Sex:**     |
| thnicity:** |                                         |              |
|             | **A -- American Indian or Alaska        | **M --       |
| **D --      | Native**\                               | Male**       |
| Hispanic or | **B -- Asian**\                         |              |
| Latino**    | **C -- Black or African American**\     | **F --       |
|             | **G -- Native Hawaiian or Other Pacific | Female**     |
| **N -- Not  | Islander**\                             |              |
| Hispanic or | **E -- White**                          |              |
| Latino**    |                                         |              |
+-------------+-----------------------------------------+--------------+

+------------------------+---------------------------------------------+
| **Do you have any      | **If yes, do you have one or more of the    |
| physical and/or mental | following targeted\* disabilities? Circle   |
| disabilities?**        | all that are applicable:**                  |
|                        |                                             |
| **Y - Yes N - No**     | **Deafness**                                |
|                        |                                             |
|                        | **Blindness**                               |
|                        |                                             |
|                        | **Missing Extremities**                     |
|                        |                                             |
|                        | **Partial/Total Paralysis**                 |
|                        |                                             |
|                        | **Convulsive Disorder**                     |
|                        |                                             |
|                        | **Mental Retardation**                      |
|                        |                                             |
|                        | **Mental Illness**                          |
|                        |                                             |
|                        | **Distortion of Limb/Spine**                |
|                        |                                             |
|                        | \* **The Equal Employment Opportunity       |
|                        | Commission targets these disabilities for   |
|                        | extra recruitment efforts.**                |
+------------------------+---------------------------------------------+
|                        |                                             |
+------------------------+---------------------------------------------+

+-----------------------------------------------------------------------+
| **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 3 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, Office of      |
| Civil Rights, 1849 C Street, NW, MS-5230, MIB, Washington, DC 20240.  |
|                                                                       |
| **PRIVACY ACT STATEMENT**                                             |
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| 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.                              |
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| AUTHORITY: Sections 1302, 3301, 3304, and 7201 of Title 5 of the U.S. |
| Code.                                                                 |
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| 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.                                                  |
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| EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. No |
| individual personnel selections are made based on this information.   |
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| DI Form -- 1935 (04/09)                                               |
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