BACKGROUND SURVEY QUESTIONNAIRE GENERAL INSTRUCTION The information from this survey is used to help ensure that agency personnel practices meet the Public Law 92-261 of March 24, 1972. Your responses are voluntary. Please answer each of the questions to the best of your ability. Read each item thoroughly. Please print your responses. PRIVACY ACT INFORMATION - GENERAL This information is provided pursuant to Public requirements of Law 93-579 (Privacy Act of 1974). December 31, 1974, for individuals completing Federal records or forms that solicit personal information. AUTHORITY Section 1302.3301, 3304, & 7201 of Title 5 of the US Code. PURPOSE AND ROUTINE USES This information is used for research and for a Federal Equal Opportunity Recruitment Program (FERRO) to help ensure that agency practices meet requirements of Federal law. EFFECTS OF NONDISCLOSURE Providing this information is voluntary. No individual personnel sections are made based on this information. INFORMATION REGARDING DISCLOSURE OF SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-359, SECTION 7(b) Solicitation of the Social Security Number is authorized under Executive Order 9397, dated November 22, 1943. NAME (LAST, FIRST, MIDDLE INITIAL)____________________________________ VACANCY ANNOUNCEMENT NUMBER_____________________________________ DATE OF YOUR APPLICATION_____________________________________ SOCIAL SECURITY NUMBER_____________________________________ YEAR OF BIRTH_____________________________________ HOW DID YOU LEARN ABOUT THE POSITION FOR WHICH YOU ARE APPLYING: (You may check up to three choices) 01__Private Information Services 02__Magazine 03__Newspaper 04__Radio 05__TV 06__Poster 07__Private Employment Office 08__State Unemployment Office 09__Agency Personnel Department (Bulletin Board or other Announcement) 10__Agency or other Federal Government Recruitment at School or College 11__Federal, State or Local Job Information Center 12__Religious Organization 13__School or College Counselor or Other Official 14__Friend or Relative Working for Agency 15__Friend or Relative Not Working for Agency 16__Other (Specify) _________________________________________ PLEASE CAEGORIZE YOURSELF IN TERMS OF THE RACE, SEX, AND ETHNIC CATEGORIES BELOW. FIRST READ DEFINITIONS OF SUBCATEGORIES. DEFINITION The racial and ethnic categories for Federal statistics and administrative reporting are defined as follows: RACE: American Indian or Alaskan Native. A person having origins in any of the original peoples of North American, and who maintain cultural identification through tribal affiliation or community recognition. Asian or Pacific Islander. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes for an example, India, Japan, Korea, the Philippine Islands, and Samoa. A person having origins in any of the black racial groups of Africa. White. A person having origins in any of the origins in any of the original peoples of Europe, North Africa, or the Middle East. ETHNICITY: Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race. RACE SEX ETHNICITY 1__American Indian or Alaskan native 1__Male 1__Hispanic Origin 2__Asian or Pacific Islander 2__Female 2__Not of Hispanic Origin 3__Black 4__ White 5__Other(Specify):_____________________ EXCEPTED APPOINTING AUTHORITIES Are you eligible for appointment under a special excepted appointing authority (Schedule A or B) for severely physically or mentally handicapped persons? __ Yes __ No EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER GENERAL INFORMATION ON MILITARY SPOUSE PREFERENCE WHAT IS IT? Military Spouse Preference (MSP) is a one-time initial employment preference for vacant positions within the Department of Defense (DoD). TO WHAT POSITIONS DOES IT APPLY? MSP applies to all positions with Appropriated Funds (AF) - General Schedule (GS), Teacher Pay (TP) and Wage Grade/Wage Leader (WG/WL), Non-Appropriated Funds (NAF and AAFES). It applies to positions that are permanent or temporary full-time, part-time or intermittent and are anticipated to last one year or longer. WHO IS ENTITLED TO FMP? Military spouses of active duty military members, who were married to their sponsor PRIOR to their PCS to the current duty station, are given this one-time preference for initial employment within the commuting area of their sponsor's permanent duty station. HOW IS FMP USED OR LOST? MSP is used or lost when a spouse accepts or declines (whichever occurs first) a permanent position or temporary position that is expected to last 12 months or longer with Appropriated Funds (AF), Non-Appropriated Funds (NAF) or AAFES. If initially appointed into a temporary position and the duration of less than one year, MSP is lost upon the extension of that appointment beyond one year. MSP is also used if a spouse preference has a series of continuous temporary appointments that cumulatively go beyond one year or longer. WHO IS NOT ENTITLED TO MSP? 1. If you marry a military member who is already stationed at their current duty station you are not entitled to MSP at this duty station. You will be entitled to MSP at your NEXT duty station. 2. Military spouses who were active duty military members when they arrived at their current duty station and then exited the military ARE NOT entitled to MSP at this duty station. You will be entitled to MSP at the NEXT duty station. TO PROTECT YOUR MILITARY SPOUSE PREFERENCE, APPLY ONLY FOR POSITIONS, GRADES, AND WORK SCHEDULES YOU WOULD ACCEPT IF THE POSITION WERE OFFERED TO YOU. DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS (DoDDS) HIGHLIGHTS OF THE MILITARY SPOUSE OVERSEAS EMPLOYMENT PREFERENCE PROGRAM With the passage of the 1985 Military Family Act, military spouses receive preference over civilian spouses and all other family members for Appropriated Fund (AF) positions at GS-15 and below or equivalent WG positions when filling the position through competitive procedures. Spouses may also receive preference for Non-Appropriated Fund (NAF) positions at grades UA-8 and below and for equivalent positions paid at hourly rates. -Military spouse preference (MSP) applies when spouses of active duty military service members are relocating due to a permanent change of station (PCS) and are seeking employment in the same commuting area as that of the military member's new duty station. -MSP applies only ONCE for initial employment into a continuing DoD position (including temporary positions scheduled to last 1 year or longer) at each new duty station. The spouse must be among persons determined to be best qualified for the position. -Employment in DoD includes AF and NAF positions. NAF is composed of AAFES (post/base exchange, Burger King, etc. and other NAF instumentalities). -When a spouse applies for a continuing position, preference is granted automatically for AF positions. The spouse is no longer eligible for MSP upon acceptance of a continuing position. -Upon declination of a continuing full-time, part-time or intermittent AF or NAF position, the spouse is no longer eligible for MSP. -Spouses may file applications for employment with DoDDS 30 days before their anticipated arrival within the command and their names may be referred, however, spouses may not receive preference until actually arriving at the overseas location. -Spouses are encouraged to apply only for those positions that they are truly interested and available. -MSP does not apply to the employment of educators within DoDDS and includes substitute teacher positions. -MSP does not apply when preference, if afforded, would result in displacement of a current employee by this action. -Spouses seeking preference with less than 6 months time remaining in the overseas area may be nonselected for permanent continuing positions. MILITARY SPOUSES MUST COMPLETE THE ATTACHED MSP FORM QUESTIONNAIRE FOR MILITARY SPOUSE PREFERENCE This questionnaire is for the purpose of determining your eligibility for Military Spouse Preference (MSP) during your sponsor's present tour of duty. Please respond to the questions listed below and submit with each application. PART I Are you the spouse of an active duty military member? ( ) Yes ( ) No If your answer is No, please complete Part III. If your answer is Yes, please complete both Part II and III. Attach a copy of your sponsor's permanent change of station (PCS) orders to the overseas command, or other appropriate documentation, to support your military spouse preference eligibility. PART II 1. When did you arrive at your sponsor's current duty station: Date:_____________ 2. Are you presently employed, or have you previously been employed at your sponsor's current duty station or within the commuting area? ( ) Yes ( ) No a. If your answer is yes, please attach a copy of your appointment record (SF 50 or equivalent form) and complete the following items: b. Who employed you? ___ CPO ___ DoDDS ___ NAF (includes AAFES & other NAF instrumentalities) ___ Other, please specify ____________________________ c. List the title and pay grade of your position(s). State how long the appointment(s) is/was scheduled to last: Position Title: ________________________________ Grade: ________ ___Permanent ___ Temporary for 1 year or more ___ Less than 1 year Position Title: _________________________________ Grade: ________ ___Permanent ___ Temporary for 1 year or more ___ Less than 1 year d. Did you ever decline a definite job offer made to you by CPO, DoDDS, or NAF? ( ) Yes ( ) No e. What is your DEROS (Date of Estimated Return from Overseas) for your current duty station (month/year)? __________________________ PART III Name (Please print): ____________________________________________________________________ Signature: ____________________________________________________________________________ =========================================================================== TO BE COMPLETED BY THE DoDDS PACIFIC PERSONNEL DIVISION Eligible for MSP: ( ) Yes ( ) No Reason if answer is No: __________________________________________________________ ________________________________________________ __________________________ Signature of DoDDS Pacific Personnel Representative Date Pre-Employment Questionnaire to Determine Eligibility for Employment INSTRUCTIONS: TO BE COMPLETED BY APPLICANTS WHO ARE RESIDING IN THE OVERSEAS AREA. The purpose of this questionnaire is to obtain information in order to determine the eligibility of applicants for Department of Defense Dependents Schools (DoDDS) positions serviced by the DoDDS Pacific Personnel Division. This form is not intended to establish overseas entitlements. Please complete all questions and return the completed form with your application for employment. Enter "N/A" if a statement is not applicable. 1. Are you a citizen of the United States? ( ) Yes ( ) No Also list additional countries you are a citizen of:_____________________________ 2. I have resided in Japan/Korea/Okinawa:_____________________________________________ (Date and Location) 3. My reason for being in Japan/Korea/Okinawa:____________________________________ 4. __ I arrived in this country to be with my military sponsor, but my trip was not at Government expense (i.e., I am not command sponsored). 5. I am an employee or family member of an employee of a private firm doing work in Japan/Korea/Okinawa. The firm's name is: ________________________________, and the expiration date of this assignment is: ________________________. 6. __ I am on contract or a family member of a person hired on contract to support the U.S. Forces. The contract is with ______________________________, and the contract provides me with an U.S. Forces identification card. The contract expiration date is ___________________. 7. __ I am retired or retiring from active military service. The date of retirement was/is: __________. 8. I have __ or have not __ been issued a work permit in Japan/Korea/Okinawa. 9. I have __ or have not __ been employed since being in Japan/Korea/Okinawa. Name of employer(s), dates and location(s) of work: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ______________________________________________ 10. I own __ or do not own __ a residence in Japan/Korea/Okinawa. 11. I have __ or have not __ paid income taxes to Japan/Korea/Okinawa. 12. Other: Please use the space below to explain answers. I understand that a false statement on any part of this questionnaire may be grounds for not hiring me or grounds for removal after I begin work. I understand it is my responsibility to notify the servicing personnel office of any changes in the information provided in this questionnaire. Signature and Date Printed Name:_______________________________________________________________ GENERAL INFORMATION ON FAMILY MEMBER PREFERENCE WHAT IS IT? Family Member Preference (FMP) is a one-time initial employment preference for vacant positions that has been granted by Congress to improve employment opportunities for family members of U.S. Armed Forces personnel and civilian employees of U.S. Government Agencies stationed in foreign areas. TO WHAT POSITIONS DOES IT APPLY? FMP applies to all positions with Appropriated Funds (AF) - General Schedule (GS), Teacher Pay (TP) and Wage Grade/Wage Leader (WG/WL), Non-Appropriated Funds (NAF and AAFES). It applies to positions that are permanent or temporary that are anticipated to last one year or longer. WHO IS ENTITLED TO FMP? Family members are defined as the spouse, unmarried dependent children including step children, adopted children, and foster children not more than 23 years of age of active duty military members and CONUS recruited U.S. citizen civilian employees of the U.S. Government Agencies including non-appropriated fund activities whose duty station is in a foreign area. HOW IS FMP USED OR LOST? FMP is used or lost when a family member accepts or declines (whichever occurs first) a permanent position or temporary position that is expected to last 12 months or longer with Appropriat ed Funds (AF), Non-Appropriated Funds (NAF) or AAFES. If initially appointed into a temporary position, the duration of less than one year, FMP is lost upon the extension of that appointment beyond one year. FMP is also used if a family member has a series of continuous temporary appointments with cumulative duration of one year or longer. TO PROTECT YOUR FAMILY MEMBER PREFERENCE, APPLY ONLY FOR POSITIONS, GRADES, AND WORK SCHEDULES YOU WOULD ACCEPT IF THE POSITION WERE OFFERED TO YOU.