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* * * Cornniun cat on Result Report (Sep. 2. 2014 12:56PM

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bate/lime: Sep. 2. 2014 12:55PM
File Page
No. Mode best nation Pg(s) Result Not Sent
0052 Memory TX 12023953888 P. 1 OK
Reason for err
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E. 3) No answer E. 4) No facs rn Ic connect on
E. 5) Exceeded max. E me I s ze E. 6) Dest nat ion does not SUOP
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U.S. Office of Personnel Management ETHNICITY AND RACE IDENTIFICATION
Guide to Personnel Data Standards (Please read the Privacy Act Statement and instructions before completing form.)
Name (Last, First, Middle Initial) Social Security Number Birthdate (Month and Year)
[Victorin Alexander H] uCC14OS.LJCC1~1O3 P.L. 93579 03/1982
Agency Use Only
Privacy Act Statement
Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance
with the Office of Management and Budgets 1997 Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity. Providing this information is voluntary and has no impact on your employment
status, but in the instance of missing information, your employing agency will attempt to identify your race and
ethnicity by visual observation. -
This information is used as necessary to plan for equal employment opportunity throughout the Federal
government. It is also used by the U.S. Office of Personnel Management or employing agency maintaining the
records to locate individuals for personnel research or survey response and in the production of summary
descriptive statistics and analytical studies in support of the kinction for which the records are collected and
maintained, or for related workforce studies.
Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be
used for the purpose of uniform, orderly administration of personnel records. Providing this information is
voluntary and failure to do so will have no effect on your employment status. If SSN is not provided, however,
other agency sources may be used to obtain it.
Specific Instructions: The two questions below are designed to identify your ethnicity and race. Regardless of your answer to
question 1, go to question 2.
Question 1. Are You Hispanic or Latino? (A person of cuban, Mexican, Puerto Rican, South or central American, or other
Spanish culture or origin, regardless of race.)
Yes [~]No
Question 2. Please select the racial category or categories with which you most closely identify by placing an X in the appropriate
box. check as many as apply. _______________________________________________________________________
RACIAL CATEGORY DEFINITION OF CATEGORY
(Check as many as apply) __________________________________________________________________
114 Amencan 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 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, the Philippine Islands, Thailand, and Vietnam.
fl 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 onginal peoples of Europe, the Middle East, or
North Africa.
Standard Form 181
Revised August 2005
Previous editions not usable
42 U.S.C. Section 2000e-16
NSN 7540-01-099-3446