Fillable Printable Ethnicity And Race Identification

Ethnicity And Race Identification

U.S. Office of Personnel Management

Guide to Personnel Data Standards

ETHNICITY AND RACE IDENTIFICATION

(Please read the Privacy Act Statement and instructions before completing form.)

Name (Last, First, Middle Initial) Social Security Number Birthdate (Month and Year)

Agency Use Only

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.)

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

(Check as many as apply)

American 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.

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.

A person having origins in any of the black racial groups of Africa.

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or

other Pacific Islands.

A person having origins in any of the original peoples of Europe, the Middle East, or

North Africa.

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

DEFINITION OF CATEGORY

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 Budget's 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 function 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.

Yes No

Standard Form 181

Revised August 2005

Previous editions not usable

42 U.S.C. Section 2000e-16

NSN 7540-01-099-3446