12
Grant Position: CRIME VICTIM ADVOCATE Position Available: Immediate Closing Date: Open Until Filled PLEASE READ THIS PAGE CAREFULLY BEFORE PROCEEDING. FAILURE TO MEET MINIMUM REQUIREMENTS OR APPLICATION INSTRUCTIONS WILL CAUSE THE APPLICATION TO BE REJECTED. THIS IS A GRANT FUNDED POSITION AND SUBJECT TO YEARLY RENEWAL GENERAL STATEMENT OF DUTIES: DUTIES INCLUDE: Providing information, general support, referrals to social and service agencies, shelter referrals, assistance with the legal system, and other assistance to victims of crime. 24-hour crisis intervention, court advocacy assistance, networking with CPS and other social agencies, transportation to shelter/medical facilities as needed and community relations. ACCEPTABLE EDUCATION AND EXPERIENCE: Candidates must have a valid Driver’s License, Bachelors Degree in Social Work or a related field, One (1) year minimum experience in social work is preferred or any equivalent combination of knowledge and abilities necessary to perform the work. NECESSARY SPECIAL REQUIREMENTS: Employees in this position are required to attend school/training as assigned. Must possess the ability to work closely with other department personnel and have a neat and clean appearance. Ability to effectively listen, retain and discern information; communicate clearly and concisely both orally and in writing. Applicant must possess basic typing skills and computer knowledge and the ability to learn a wide variety of skills for the job. Conviction or withheld judgment of any state, local or federal crime may be grounds for rejection. APPLICATION: APPLICATION MUST BE FILLED OUT COMPLETELY AND ACCURATELY. NOTARIZED APPLICATIONS MUST BE RETURNED TO HUMAN RESOURCES ON THE SECOND FLOOR OF CITY HALL LOCATED AT 408 N SPOKANE STREET. TO ENSURE PRPER PROCESSING, PLEASE DO NOT FOLD APPLICATION. FAXED APPLICATIONS WILL NOT BE ACCEPTED WITHOUT PRIOR APPROVAL. POSITION IS OPEN UNTIL FILLED. SELECTION PROCESS: A LETTER WILL BE SENT VIA POST OR EMAIL SHORTLY AFTER APPLICATIN IS RECEIVED AND PROCESSED. STATUS NOTIFICATION MAY TAKE UP TO SIX (6) WEEKS. SELECTION PROCESS CONSISTS OF AN ORAL BOARD INTERVIEW, COMPLETE AND THOROUGH BACKGROUND INVESTIGATION, POLY GRAOH EXAM AND FINAL INTERVIEW WITH THE CHIEF OF POLICE. YOU MAY BE REQUIRED TO DEMONSTRATE THE ABILITY TO PERFORM JOB REQUIREMENTS. HIRING RANGE: $17.60 - $19.01 DOE AND A COMPETITIVE BENEFIT PACKAGE. EOE The City of Post Falls is an Equal Opportunity Employer. If you should need assistance or accommodation during the application process, please contact the Human Resource Department at 208-457-3326 or 208-457-3316. CITY OF POST FALLS POLICE DEPARTMENT Position Posting Notice June 12, 2017

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Page 1: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Grant Position: CRIME VICTIM ADVOCATE

Position Available: Immediate

Closing Date: Open Until Filled

PLEASE READ THIS PAGE CAREFULLY BEFORE PROCEEDING. FAILURE TO MEET MINIMUM

REQUIREMENTS OR APPLICATION INSTRUCTIONS WILL CAUSE THE APPLICATION TO BE REJECTED.

THIS IS A GRANT FUNDED POSITION AND SUBJECT TO YEARLY RENEWAL

GENERAL STATEMENT OF DUTIES:

DUTIES INCLUDE: Providing information, general support, referrals to social and service agencies, shelter referrals,

assistance with the legal system, and other assistance to victims of crime. 24-hour crisis intervention, court advocacy

assistance, networking with CPS and other social agencies, transportation to shelter/medical facilities as needed and

community relations.

ACCEPTABLE EDUCATION AND EXPERIENCE:

Candidates must have a valid Driver’s License, Bachelor’s Degree in Social Work or a related field, One (1) year minimum

experience in social work is preferred or any equivalent combination of knowledge and abilities necessary to perform the

work.

NECESSARY SPECIAL REQUIREMENTS:

Employees in this position are required to attend school/training as assigned. Must possess the ability to work closely with

other department personnel and have a neat and clean appearance. Ability to effectively listen, retain and discern information;

communicate clearly and concisely both orally and in writing. Applicant must possess basic typing skills and computer

knowledge and the ability to learn a wide variety of skills for the job. Conviction or withheld judgment of any state, local or

federal crime may be grounds for rejection.

APPLICATION:

APPLICATION MUST BE FILLED OUT COMPLETELY AND ACCURATELY. NOTARIZED APPLICATIONS MUST

BE RETURNED TO HUMAN RESOURCES ON THE SECOND FLOOR OF CITY HALL LOCATED AT 408 N

SPOKANE STREET. TO ENSURE PRPER PROCESSING, PLEASE DO NOT FOLD APPLICATION. FAXED

APPLICATIONS WILL NOT BE ACCEPTED WITHOUT PRIOR APPROVAL. POSITION IS OPEN UNTIL FILLED.

SELECTION PROCESS:

A LETTER WILL BE SENT VIA POST OR EMAIL SHORTLY AFTER APPLICATIN IS RECEIVED AND

PROCESSED. STATUS NOTIFICATION MAY TAKE UP TO SIX (6) WEEKS. SELECTION PROCESS CONSISTS OF

AN ORAL BOARD INTERVIEW, COMPLETE AND THOROUGH BACKGROUND INVESTIGATION, POLY GRAOH

EXAM AND FINAL INTERVIEW WITH THE CHIEF OF POLICE. YOU MAY BE REQUIRED TO DEMONSTRATE

THE ABILITY TO PERFORM JOB REQUIREMENTS.

HIRING RANGE: $17.60 - $19.01 DOE AND A COMPETITIVE BENEFIT PACKAGE. EOE

The City of Post Falls is an Equal Opportunity Employer. If you should need assistance or

accommodation during the application process, please contact the Human Resource Department at

208-457-3326 or 208-457-3316.

CITY OF POST FALLS

POLICE DEPARTMENT

Position Posting Notice

June 12, 2017

Page 2: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Crime Victim Advocate

1

CITY OF POST FALLS CLASS SPECIFICATION

CRIME VICTIM ADVOCATE

Pay Grade: 8

FLSA Designation: Non-exempt Updated: 06/02/2017

General Statement of Duties Provides information, support, and referrals to victims of crime; performs related work as

required.

Classification Summary The primary function of an employee in this class is to provide information, general

support, and referrals to agencies and providers to victims of crimes; provides crisis

intervention services. The work is performed under supervision of the Detective

Sergeant, with considerable latitude granted for the exercise of independent judgment and

initiative. The principal duties of this class are performed in a public office building but

include responses to crime scenes, which may include exposure to dangerous situations.

Examples of Work (Illustrative Only)

Essential Duties and Responsibilities:

Provides information, general support, referrals to social and service agencies, shelter

referrals, assistance with the legal system, and other assistance to victims of crime;

Provides crisis intervention services at crime or accident scenes;

Provides assistance to all Divisions in the Department with crime and accident

victims;

Responds to crime scenes, hospital and emergency medical facilities;

Transports victims needing shelter or medical assistance and to court proceedings;

Provides training to all Department personnel, and other agencies as needed, on crime

victim issues;

Assists crime victims in obtaining temporary shelter or housing as needed;

Provides crime victims with referrals to social and service agencies, state agencies,

support groups, counseling options, and other available assistance;

Provides assistance during and information on legal proceedings;

Testifies in court as needed;

Assists officers in investigations, including taking statements, photos, and other

information and providing supplements to reports;

Performs community and public relations, providing information outreach to

community and civic groups, and other interested groups;

Provides clerical support and performs office duties;

Performs all work duties and activities in accordance with Post Falls Police and City

policies, procedures, and safety practices.

Page 3: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Crime Victim Advocate

2

Keeps monthly and quarterly statistics for grant reporting and annual reports;

Assist in researching and writing grants.

Other Duties and Responsibilities

On call after regular work hours to respond to emergency situations;

Performs other related duties as required.

Knowledge, Skills and Abilities Knowledge of:

Methods, practices, procedures, and objectives of crime victim assistance and

counseling;

Methods, practices, and objectives of crisis intervention;

Police response and investigative methods and procedures;

Victim assistance resources available, including but not limited to, social and service

agencies, shelters, counseling and support groups, financial and other aid, and related

sources;

Applicable federal, state, and City laws, statutes, codes, and ordinances;

Court and legal procedures.

Ability to:

Follow written and oral instructions;

Learn and apply Post Falls Police and City policies regarding safe work practices in

dangerous, hazardous, and stressful conditions.

Establish communications and working relationships with crime victims and police

officers, including under stressful or dangerous conditions;

Evaluate persons and situations quickly and accurately;

Remain alert to dangers and hazards in stressful situations;

Accurately record statements from victims, including written or oral statements, and

process photographic evidence;

Operate a motor vehicle;

Operate audio and video equipment;

Operate standard office equipment, including a personal computer with program

applications appropriate to assigned duties;

Perform multiple tasks simultaneously, including handling interruptions, and return to

and complete tasks in a timely manner;

Perform time management and scheduling functions, meet deadlines, and set project

priorities;

Communicate effectively with the public and other employees.

Acceptable Experience and Training Bachelors degree in social work or a related field;

One (1) to two (2) years experience in social work preferred; or

Any equivalent combination of experience and training which provides the

knowledge and abilities necessary to perform the work.

Page 4: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Crime Victim Advocate

3

Special Qualifications Valid driver’s license;

Essential Physical Abilities Sufficient clarity of hearing and speech, with or without reasonable accommodation,

which permits the employee to discern verbal instructions, and to communicate with

other employees and the public in person and by telephone;

Sufficient visual acuity, with or without reasonable accommodation, which permits

the employee to comprehend written work instructions, see and assess situations and

physical surroundings under stressful conditions, and prepare and evaluate a variety

of written and text documents;

Sufficient manual dexterity, with or without reasonable accommodation, which

permits the employee to operate photographic and audio equipment, standard office

equipment including a personal computer, and make adjustments to equipment;

Sufficient personal mobility, flexibility, and agility, with or without reasonable

accommodation, which permits the employee to work in an office and field

environment.

Page 5: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Application for Employment 408 N. Spokane St., Post Falls, ID 83854 Phone: 208-457-3316; FAX 208-457-3356

www.postfallsidaho.org

The City of Post Falls is an Equal Opportunity employer. If you need assistance or accommodation in completing the application process, please contact the Human Resources Office at 208-292-2316 or 292-2326.

Position Applied for: Crime Victim Advocate Date of Application:

Name: Last First Middle Social Security Number

Present Address: Number Street/P.O. Box City State Zip

Phone: E-Mail/Message Phone:

List all past addresses since 18 YOA (If more space needed, attach a separate piece of paper)

Past Address: Number Street/P.O. Box City State Zip

Past Address: Number Street/P.O. Box City State Zip

Past Address: Number Street/P.O. Box City State Zip

Past Address: Number Street/P.O. Box City State Zip

Past Address: Number Street/P.O. Box City State Zip

Past Address: Number Street/P.O. Box City State Zip

Availability: Date Available: Type Position:: Full Time Part Time Temporary

Days/Hours you are available to work: (Check all below that apply) Weekdays ( to ) Saturday Sunday Evenings Overtime

Are you willing to perform job-related travel? Yes No (Check all that apply) overnight 1 week longer

Personal: Check here if you are between the ages of 14 and 18. (Subject to work restrictions.)

Are you legally eligible for employment in the United States? Yes No (Proof of citizenship or immigration status will be required within 3 days of employment.)

Have you ever been convicted or pled guilty to a felony or a misdemeanor, including withheld judgments and bond forfeiture? Yes No If yes, give details below. (This will not necessarily disqualify you.)

State Law restricts some employment of relatives. List name and position of any City employees who are relatives by blood, adoption or marriage:

Do you have a valid driver’s license? Yes No Commercial Drivers License? Yes No (required to drive city vehicles)

List State: Number: Date Expires:

Page 6: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Revised 01/17/08

Have you ever worked for or applied for work with the City of Post Falls before? If yes, list dates and name if different.

Have you ever been involuntarily terminated from employment or asked to resign in lieu of proposed termination? Yes No If yes, can the terms be disclosed by you? Yes No If yes, explain on separate sheet of paper.

Idaho law provides for veterans preference to State residents who have been in the military service of the United States during a RECOGNIZED WAR PERIOD as defined by law. I wish to claim preference. ( Attach DD-214 form to claim preference or if currently serving, copy of valid ID card.)

Have you ever been employed under a different name? If yes, list name and dates of employment.

Education: Do you have a high school diploma or equivalent (GED)? Yes No

If Yes, Name of High School:

Check the box showing the highest grade completed Elementary 7 8 9 10 11 12

Special Training or Education beyond High School Name and Location of School

Major Course of Study

If No Degree, Credit Hours Completed

Type of Degree or Certificate and Date Received

Special Skills: Typing or computer keyboarding experience? Yes speed _________ No IBM Compatible Personal Computer experience? Yes years/mo_______ No List Software Programs you have worked with: Word Processing: Spreadsheet: Database: Browser: Other Software:

List other job-related skills, licenses, certifications, or memberships in professional organizations:

Employment History: Beginning with your present or most recent employer, list all positions for at least the last ten years and other positions relevant to the position for which you are applying. If you have held more than one position for the same employer, list each separately. ACCOUNT FOR PERIODS OF UNEMPLOYMENT. Include self-employment and military service. List volunteer work related to the position. You may continue your response by duplicating additional copies of the next page. Applications which say “see resume” will not be accepted if the resume does not provide all requested information.

Page 7: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Revised 01/17/08

Employment History

EMPLOYER: DATES OF EMPLOYMENT:

SUPERVISOR: PHONE: MAY WE CONTACT? YES NO

ADDRESS: CITY: STATE: ZIP:

JOB TITLE: HOURS PER WEEK: SALARY:

DUTIES:

REASON FOR LEAVING:

EMPLOYER: DATES OF EMPLOYMENT:

SUPERVISOR: PHONE: MAY WE CONTACT? YES NO

ADDRESS: CITY: STATE: ZIP:

JOB TITLE: HOURS PER WEEK: SALARY:

DUTIES:

REASON FOR LEAVING:

EMPLOYER: DATES OF EMPLOYMENT:

SUPERVISOR PHONE: MAY WE CONTACT? YES NO

ADDRESS: CITY: STATE: ZIP:

JOB TITLE: HOURS PER WEEK: SALARY:

DUTIES:

REASON FOR LEAVING:

EMPLOYER: DATES OF EMPLOYMENT:

SUPERVISOR: PHONE: MAY WE CONTACT? YES NO

ADDRESS: CITY: STATE: ZIP:

Page 8: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Revised 01/17/08

JOB TITLE: HOURS PER WEEK: SALARY:

DUTIES:

REASON FOR LEAVING:

EMPLOYER: DATES OF EMPLOYMENT:

SUPERVISOR: PHONE: MAY WE CONTACT? YES NO

ADDRESS: CITY: STATE: ZIP:

JOB TITLE: HOURS PER WEEK: SALARY:

DUTIES:

REASON FOR LEAVING:

Given your knowledge, skill, education and experience, are you able to perform all the essential elements of the position for which you are applying as set forth in the job description with or without special accommodation? Yes No If no, what accommodation(s) would be required to perform the essential elements of the position?

Employment References: (INCLUDE INDIVIDUALS WHO ARE QUALIFIED TO EVALUATE YOUR CAPABILITIES AND ARE NOT EITHER PREVIOUS SUPERVISORS OR RELATED TO YOU.)

Name/Occupation Address City State, Zip Phone

Page 9: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Revised 01/17/08

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION AND AUTHORIZATION AND RELEASE REGARDING BACKGROUND INVESTIGATION OF POLICE DEPARTMENT APPLICANT

I, , am making application to become an employee for the Post Falls Police Department. I am currently employed at ______________________________.

I fully understand that the Post Falls Police Department will perform a complete and thorough background investigation to ensure that I have the necessary skills, abilities, and character to properly perform the duties as an employee for this agency. I recognize and understand that the referenced background investigation will include, but will not be limited to inquiries that are designed to determine and/or confirm my personal history and to determine whether or not I have at any time in the past or am presently involved in any conduct which the Post Falls Police Department deems unacceptable would disqualify me from employment, including but not limited to criminal misconduct, domestic violence, use of illegal drugs, dishonesty and/or immoral behavior, misconduct in other employment, etc. I fully understand that I will be asked to submit to a polygraph examination and asked many questions, including any information that I provide or is obtained as a result of the referenced background investigation. I also understand that the information obtained by virtue of the referenced background investigation may result in my not being hired by the Post Falls Police Department.

It is my intent by this authorization to give my consent for full and complete disclosure of any and all records regarding myself, including but not limited to records of educational/training institutions; financial or credit institutions; any and all records regarding any of my previous employment, including but not limited to all such employment or pre-employment records, including prior background investigations, performance/efficiency reports, complaints or grievances filed by or against me and any and all related records, including records and/or recollections of any and all attorneys at law, or other counsel, whether representing me or another person in any case, either criminal, administrative or civil in which I presently have or have had an interest.

I understand that any information obtained as a result of the referenced background investigation which is developed directly or indirectly, in whole or in part, based upon this authorization will be considered in determining my suitability for employment with the Post Falls Police Department.

With full recognition of the above, I hereby give the Post Falls Police Department full and complete authorization to conduct the referenced background investigation regarding me. Further, I do hereby release the City of Post Falls, the Post Falls Police Department and any and all employees or representatives of said City, along with all persons or entities, whether public or private, who provide information to the representatives of the City of Post Falls who are conducting this background investigation from any and all liability, claims, allegations, lawsuits, however characterized, which may arise or be incurred as a result of the referenced background investigation. Further, in the event I am currently employed by a law enforcement agency, whether employed as a law enforcement officer, correctional officer, dispatcher or any other position with a criminal justice related agency of any type, I understand that information obtained during this investigation and/or the results of this background investigation may be made available to my current employer, whether or not I am offered employment with the Post Falls Police Department. I understand that this disclosure may result in adverse consequences to me, in my current job, including but not limited to termination from employment, negative reference information being provided in the future and possible criminal investigation and/or prosecution. In signing this authorization I acknowledge that I understand and agree that this constitutes a complete and final release from liability and shall foreclose any and all claims, allegations, lawsuits or causes of action of any nature, whether legal or equitable, which I may have against any persons or entities who participate in the referenced background investigation or provide any information in response to any inquiries arising out of the referenced background investigation and I expressly acknowledge that I, my heirs, executors, administrators, successors, assigns, etc. are completely foreclosed from pursuing any claims for any form of relief, damages, fees, costs, etc. under any rule or provision of law, either state or federal, that are in any way related to the referenced background investigation.

I expressly agree that a photocopy of this form will be as valid as an original thereof, even though said photocopy does not contain an original writing of my signature.

______________ Applicant’s Signed Date Signed

_______________________

State of _________________________, County of ________________________________

On this ___________ day of _______________ . 20______,

_______________________________________ personally appeared before me,

_______ who is personally known to me

_______ whose identity I proved on the basis of _______________________________

_______ whose identity I proved on the oath/affirmation of

________________________________, a credible witness,

to be the signer of the above instrument, and he/she acknowledged that he/she signed it.

________________________________ , Residing at ____________________________

My commission expires ____________________________________________________ Notary Stamp Here

Page 10: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Revised 01/17/08

Supplemental Questionnaire for Employment with the Police Department

The following information is requested for the background investigations to be considered for employment with the Police Department of the City of Post Falls. Attach additional pages if needed.

1. Your date of birth will be used only for purposes of obtaining driving, criminal history and other relevant records.

Date of Birth: Drivers License #: State of Issue:

2. Do you object to wearing a uniform? No Yes

3. Have you worked shifts in the past? No Yes Check those you have worked: Day Swing Night

4. List any contact or use including experimentation, ingesting, or inhaling of any illegal substance including but not limitedto marijuana, cocaine, speed, LSD, Meth, “mushrooms” and hashish, or prescription drug which was not prescribed to you by a licensed physician. List date and drug and any explanation. An entry in this section does not automatically disqualify you from consideration; however, failure to list any incident that is discovered later in the background investigation may be grounds for disqualification or dismissal.

Date last used: # Times in Life: Drug: Explanation:

5. Have you ever been arrested, detained, or issued a citation (excluding traffic infractions) by a law enforcement agency?No Yes If yes, complete the blocks below. Repeat any information already provided elsewhere. An entry in this section does not automatically disqualify you from consideration; however, failure to list any incident that is discovered later in the background investigation may be grounds for disqualification or dismissal.

Date: Charge: Agency: Disposition: Date: Charge: Agency: Disposition:

6. List any traffic violations relative to which a judgment of guilt was entered.

Date: Violation: Judgment:

7. Have you ever used tobacco? No Yes If yes, list most recent time.

8. Have you ever been a candidate, successful or unsuccessful, for another position requiring peace officer powers?No Yes If yes, give details below:

Date: Agency: Circumstances:

8. For Patrol Officer candidates only, supply the following information for Police Officer Standards Training (P.O.S.T.)

Height: Weight:

Page 11: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

Name:_________________________

Lack of one or more skills will not necessarily disqualify you from consideration for the position if you meet the basic minimum qualifications stated on the job posting.

City of Post Falls, ID Supplemental Questionnaire

Crime Victim Advocate

1. Rate your expertise and list length of experience for the job skills below:

Skill

Haven’t

Done

Some

Knowledge Expert

Length of

experience

(years/months) Knowledge regarding domestic violence & victimization

Crime victim assistance

Knowledge of Idaho laws on domestic violence

Work closely with law enforcement at crime scene

Work under extreme stress

Knowledge of Idaho court system

Ability to talk tactfully with diverse people

Write reports and correspondence

Crisis intervention training or experience

Ability to multitask

2. Rate your knowledge and experience with the following computer programs:

Program None Some Much Version Last Time Used

Internet Search Engines

Windows

Word

Excel

Other:

3. Circle which days and times of the day you are usually available to work.

Sun Mon Tue Wed Thurs Fri Sat

Morning Morning Morning Morning Morning Morning Morning

Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon

Night Night Night Night Night Night Night

Page 12: Crime Victim Advocate Applicatin Packet - postfallspolice · Crime Victim Advocate 2 Keeps monthly and quarterly statistics for grant reporting and annual reports; Assist in researching

DEMOGRAPHIC INFORMATION ON APPLICANTS

Position Title:

Date Applied:

YOUR PRIVACY IS PROTECTED

This information is used to determine if our equal employment opportunity efforts are reaching segments of the population

consistent with Federal equal employment opportunity laws. Responses to these questions are voluntary. Your responses

will not be shown to the panel rating the application, to the official selecting an applicant for a position, or to anyone else

who can affect your application. This form will not be placed in your Personnel file nor will it be provided to your supervisors

in your employing office should you be hired. The aggregate information collected through this form will be kept private to

the extent permitted by law.

Completion of this form is voluntary. No individual personnel selections are made based on this information. There will

be no impact on your application if you choose to not answer any of these questions.

Thank you for helping us to provide better service.

1. How did you learn about this position (Check One):

☐Agency Internet Site Recruitment

☐Private Employment Web Site

☐Other Internet Site

☐Job Fair

☐Newspaper or magazine

☐Agency or other Federal Government on campus

☐School or college counselor or other official

☐Friend or relative working for this agency

☐Private Employment Office

☐Human Resources Department (bulletin board or other announcement)

☐Federal, State, or Local Job Information Center

☐Other:______________________________

2. Sex (Check One)

☐Male

☐Female

3. Ethnicity (Check One)

☐Hispanic or Latino – a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish

culture or origin, regardless of race.

☐Not Hispanic or Latin

4. Race (Check all the apply):

☐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 have origins in any of the original people of the Far East, Southeast Asia, or the Indian

Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Island, 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 Africa.