Application for Employment - Iowa

CFN 552
0072 R 1/07
Section 5 Applicant Survey
Social Security or Alternate Number
This information is requested as a part of Iowa state government’s responsibility to maintain a nondiscriminatory workplace and to
provide equal employment opportunity for all. Your responses are deemed confidential, and this section is removed before your
application is processed. The information you provide is only used in summary reports to assist the Department with planning,
monitoring and evaluating its equal opportunity programs. Providing this information is voluntary; however, your cooperation is
critical to ensuring we have a diverse workforce. Your choice not to self-disclose will not adversely affect you as an applicant.
Please write your numbered response to questions A through F in the corresponding boxes.
A. What sex are you?
0. Male
1. Female
C. What is your highest level of education?
0. 0-8 years
1. 9-12 years, but not a high school graduate
2. High school graduate or GED
3. Post high school vocational or business school
4. Some college, less than BA or BS degree
5. BA, BS or similar undergraduate degree
6. MA, MS or similar graduate degree
7. PhD, JD or similar professional degree
8. MD or similar professional degree
E. Do you have a disability?
(An individual with a disability is any person who: (1) has a
physical or mental impairment that substantially limits one or more
major life activities; (2) has a record of such impairment; (3) is
regarded as having such an impairment.)
Examples of disabilities:
Physical or mental impairment Any physiological disorder or
condition, cosmetic disfigurement, or anatomical loss affecting
one or more of the following body systems: neurological,
musculoskeletal, special sense organs, respiratory (including
speech organs), cardiovascular, reproductive, digestive,
genitourinary, hernic and lymphatic, skin and endocrine.
Major life activities means functions such as caring for one’s
self, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning, working, and receiving education or vocational
0. No
1. Yes
2. Do not wish to self-disclose
B. What is your age?
0. under 18
1. 18-29
2. 30-39
3. 40-49
4. 50-59
5. 60-69
6. 70 or over
D. Of which racial/ethnic group do you consider yourself a
0. White: (Not Hispanic or Latino) A person having origins in
any of the original peoples of Europe, the middle East, or
North Africa
1. Black or African American: (Not Hispanic or Latino) A
person having origins in any of the black racial groups of
2. Asian: (Not Hispanic or Latino) A person having origins in
any of the original peoples of the Far East, Southeast Asia,
or Indian Subcontinent
3. American Indian or Alaska Native: (Not Hispanic or Latino)
A person having origins in any of the original peoples of North
and South America (including Central America), and who
maintain tribal affiliation or community recognition
4. Hispanic or Latino: A person of Cuban, Mexican, Puerto
Rican, Central or South American, or other Spanish culture or
origin, regardless of race
5 Native Hawaiian or Other Pacific Islander: (Not Hispanic or
Latino) A person having origins in any of the peoples of
Hawaii, Guam, Samoa, or other Pacific Islands
6 Two or More Races: (Not Hispanic or Latino) All persons
who identify with more than one of the above five races
F. How did you learn about this job?
0. Direct contact with DAS-HRE at its office, Job Information
Center or through its Jobline
1. Iowa Workforce Development (IWD) Center or IWD Website
2. Iowa state agency or a state employee
3. Contact with state agency other than those listed in
0, 1, 2, 8 & 9
4. Public Library
5. Internet/website other than the DAS-HRE and IWD websites
6. College, university or community college career or
placement offices
7. Newspaper, periodical or trade journal
8. Career fair attended by a state of Iowa agency
9. DAS-HRE website
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