Applicant Survey (United States)
This form is used to apply for a job for the U.S. Department of Justice, Immigration and Naturalization Service. The form provided here is simply a sample of what the actual Form G-942 looks like.
UNITED STATES DEPARTMENT OF JUSTICE
Immigration and Naturalization Service
PURPOSE AND ROUTINE USES
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.
PRIVACY ACT INFORMATION
General - 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.
Authority - 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.
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.
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.)
Yes ____ No ____
INFORMATION ON RACE/ETHNICITY, SEX AND DISABILITY STATUS
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. 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.
2. 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).
3. 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).
4. 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.
5. 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.)
____ A. Mexican
____ B. Puerto Rican
____ C. Cuban
____ D. Central American
____ E. South American
____ F. Other
____ SECTION B. SEX ____ 1. Male ____ 2. Female
____ SECTION C. DISABILITY STATUS
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.
06. Handicap not listed.
16. Total deafness in both ears, with or without understandable speech.
23. Inability to read ordinary size print, not correctable by glasses (can read oversize print or use assisting 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.
35. Missing one hand 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
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.
____ SECTION E. RECRUITMENT INFORMATION
HOW DID YOU HEAR ABOUT THE POSITION FOR WHICH YOU ARE APPLYING? (Check all boxes which apply).
____ A. Friend in INS
____ B. Friend not in INS
____ C. Agency Personnel Office
____ D. Vacancy Announcement
____ E. Another Federal Agency
____ F. DOJ Career Opportunities
____ G. Office of Personnel Management
____ H. College or University
____ I. Radio
____ J. Military Installation
____ K. Federal Research Service
____ L. U.S. Employment Service
____ M. Newspaper
____ N. Television
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 information. 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.