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ETHNICITY AND RACE IDENTIFICATION

U.S. Office of Personnel Management

Guide to Personnel Data Standards

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

Name {Last, First, Middle lnitial}

ffi

!\&l prr ETRraunu 5

As"*y

u;3rly

Birthdate {Month and Year)

[i*te

*i"rr

JBi?

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 Offite of Management and Budget's 1997 Revisions to the Standards for the Classification of Federal Data on Race
and Ethnicity. erovidlng 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. lt
is also used by the U. S. Ofiice 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.
Sociat Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be used
for the purposl of uniform, orderty administration of personnel records. Providing this information is voluntary and failure
to do so will have no effect on your employment status. lf SSN is not provided, however, other agency sources may be
used to obtain it.
Specific lnstructions: The two questions below are designed to identify your ethnicity and race. Regardless of your answer to
question 1, go to question 2.

1. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origip, regardless of race.)

Question

[Yes &

Question

2. Ptease

ruo

n" o"i"t

box. Check as many "ubE

as apply.

""t"gof

or calegories with which you most closely identify by placing an "X" in the appropriate

RACIAL CATEGORY
(Check as many as apply)

,,6bSmerican lndian or Alaska Native

DEFINITION OF CATEGORY

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 lndian subcontinent including, for example, Cambodia, China, lndia'
Japan, Korea, Malaysia, Pakistan, the Philippine lslands, Thailand' and Vietnam.

Btacx or African American

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

ff

Native Hawaiian or Other Pacific lslander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.

lprWnite

A person having origins in any of the original 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{99-3446

TRAHSMISS]I]N UEH]FICATIOI{ EEPI]RT

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PAGE {5}
ffiEEI_iLT

OK

STAHDARD

tdttlrf

Cover Sheet

l;lir:

rt U.S-C 1-4

55 and 5S

folrgressional Record

A3IZZ0 of May 11, 1955

sectlons 7 lcl,7 {e},9, t2

r-!i:* 5# U.5,C
trS17 Tnading

unlted Natiorts Charter;

wltlt the

lnter-Amerlcan Be,

the right of lndlgenL

Tltle 42 u,s,c 1985

4E stat,

Act

rffil;

54 stat

Title 28 U.S.C u33.

l-o;'i'Thr riffice

ent and Budget

of

7?5 l?th $treett,

Wachington,

EIC

Fax 202-395-3888
.;i"&ffr: Slnnya Michelle

tc:

$F 1&[ Fsrm

'!

",=":';',ii:+ET'-?

110'r'u CION(+RES!

1s'rS,i-sstriN'

,\yrolotrizirrg^

iol

t\-

H. RES. 194

tiic, euslavcrrrcnl arttl ltrt'ial sc3-t'r-'gation ol ^\l'r'it'arl-r\lttt't'it'tLtis

IN TIII] iIOT S]T O1.' RIiI'IIESI]NT.\1'I\'1]S

lL.

I.'tiunt',tnl' J7, ?007

(-ltltil.;N (tirr. liirirsr'1f. lh'. JtlIlSsttN of (it'oIgia, )Is, ..I-tt l(sU)t-i-Iill of
Tr:xrrs. llr.. Iln-UrV o1' Pcrtttsrt'airia, lh'. \\'nrr,Cn, ]Is. Iitl,p-r't'tltt'ti' JIs.
\Yool.srir'. lir'. P-u,r.osr, ^\Is. 1,ril.t. llt.. ^\lt (iovtins, ,\l'. St'II-\Iio\YsI(Y,
Jh.s. ]Lti-oNIIY of \t'l'Yrtr'li, ]h'. L'tixrstls, )h'. llrrti-Ls of \-ilgirriir. lh'.
('_rl,u_tNo, JIt'. R-r.sr;rit,. JL.. I'.rt'Nti. ]h'..Ilitt-unsos, f,L'. Eli,tstlx. llr.
lt. (iuutis of Texrrs, llr'. Iit"r"ul1ll,'Ilil-1). Jis. \\--r'rsos, llr'. IItxt'rinr-,
lh,. Cr,U-stt, )Is. C-tlisoN. Jh'. Istt-Ltit,, Jir'. ,\trlrlli-\LL\, fL'. I)-rlis of
.\lrrlrarnu, ]Ii'. Lrilts of Gcolgitr. JIi'. -\f',gtttlltOlll']IE. fIr' lI-t'ttC. Jh'.
Ifitxstior*. JIs. Ii-u.nu'rs. Jir.. IIolns, lL,. Iru,Xlttr, -\h'. IIoxu-r. antl
lh.. I(t,t'txtLlH) su.l)Illittetl tlr tollol'iug lt'solutir-rtt: l'Iiit'h l'as l'r'tt'r't't't1 tti
the Clornutittct' ott tlrt' ,hirliciai'r'

RESOLUTION
Apologizilr-q'tgi.the enslttyttlli'nt illl(1 rai'itll st'g't'i'galiutt of
-..\frit,ar r--\ti

\\'1iet'eus trrillirttrs
cnsiavi,tl

t'i('itl ls,

of -\fi'it'atrs alld theit'

dest'ettciattts \\'L're

iti tltt, Llnitecl States ancl tiie 1ll Arlt'i'ical]

tuics frottr 1619

colo-

througli 18ti5;

\\'lterens slaver..t' in .\merit,rt resernltlecl tto rttlter' 1'(tl'ttt <lf itn-oluutai.)' seiritutie ktlolu in ltiston', as -Vi'iealls \Y(-'l'e cal)tru'crl ancl solrl at auction lilie itiirttitttate objccts o1' allir'." l.'.

\Vhereas r\fricarts f'orcecl into sletver)- \\'ere bnrtalized, Iturnili-

ated, clehumanizecl, ancl subjectecl to the indignitv of

[ging stripped of their names and ]rerittrge;
\\lrerea.s ettslavecl fainilies \\'ere tortt apart after hiivitrg beetl
sold scparatell. flom onr: another;

\Vlrtreas thc s1'stein of slavt,r'r' ancl the yisceritl racist'i't tigttittst

persolrs of ,\frit'ati clest'ettt llpoll rvhit'h it cleperrdecl becarne eirtrencht:cl in tlic Natiotr's stictial tabrirr;
\Yliereus slar,erJ'l.its uot ofticialll' abolislrccl until tllc passage
of tlie 13tlr Anreric'lnrerrt to tlre Llriitecl Staites (lorrstitu-

tion in 1865 after

ther cncl

of thc'CiYil \\'ar, u'hicli

u'as

fbught over the slult,t'r). issue;

\\Ilrerezts after sm;lltlripzttiori ti'ottt 246 .r'ears of slalvery, African-Americans soon sa\\' the fleetiiig' ltolitical, social, and

econotuic ga,ins thev ntaclg during Reconstmction c.,'isceratecl b1' rirulerrt rtir:isnr, lr'tttrhirrgs, clisettfratichi semeitt,
Rlack Cocles, ancl racial segregation las's that irnposecl a
rigid s).Stem ofl officialh- sanctioned racittl seg,'t't'g'ation ilr

virttrallr, all areits of lifer

\Yliereas tlie s\.stom of c1c jru'e t'acial seg'r'egation knol'n as
".Iirn ('r'o\\,," rvhicir aI'osc iit certaitr ltarts of tht' Natiori
firlltxvirrg tlre Civil \Yetr to t'reitte sepat'atte ttttcl ttttequitl
socictics fot' u.hites atttl Afi'icari-Amel'icalts, \\'as a dii'et:t
result of tltcr racisttt against persons of Afi'ican tlescerit
erigenclerecl bv slttr,er)';

of Jitu L'ror. lau's officially c'ristecl into

tlie 1960's-il treittur)' after the official encl of slavery irl
.\rlierir,tt-urrtil Congress took atrtitltt to ertd it, but tlre
r,estig'es of Jim Crort cotrtinue to this cla;';

\Vltc,reas the svsti:m

\Yhereas .\frican-Anericaus contiuue

seqlleti(,es

of slaven'

.HRES 194 IH

artcl

to suffer from the

con-

Jinl tlr<lu'-l1;1i,' aftcr llotlr svs-

:l

terns \\'el'e fonnallr' altolisheri-tlu'oug'lt ettorntous clattiztge

ltoth tatrgiltkr and intangiblt', inchrtliirg tltc loss

of hurnatr clignrtl ancl libt,rt1,, tltc fitstratitlir of' Cilreel'S
ancl plofessiorrzri lives, ancl the klttg'-tertu loss ttf ittt't-rttie
anil ripportuuitr';
arrcl ioss,

\\-het'r'tts thc storv of'tlre l'ttslttrt'titettt ttttcl

clt,jtii't

st3r'egtttiotr

atrtl tlre (lt'lttttttitttizirrg att',r'ities

critntnittetl agairrst tltt,ttr slronlt'l tiot lre llurg,trl Ii'oin or'
ittitriiuizt'cl in tite tcllitrg of Attict'ic'ait ltistot'r'l

0f

,\1't'i.att--,\tuet'it'tttts

tlil; to Lioi't'e IslarrLl, Serreg.'irl, a forrttttt' slave 1tort, Pt'gsitlellt Gt'oi'g.c \\'. l3rtsii tlc-

\Ylrererts

rnt,Itth'8,

200:1. tlLrrirrg a

knorviedgetl slin'et']"s cr-itrtiituiug legrtcf

irl Aneritan liit:

tire neecl to r.onfront tlrat leg'ar'1- u'lreti lie statecl tlrat

otic off the gr('atest ct'iures of ltiston'
slavei'.r' "\\'as
. The ritcial bigotrv terl ln' slartr'.1' r1icl not cnd u'ith
siiit'et'1' or t'ith segregatittlr. -hicl tltittlt' of tltt' isstres tlrat
still troulrlc Anerica irale i'oots iu thc lrittet' exl)et'iertcc
clf' clther tirnes. But liott't'r'et' lottg thc jounx'\', o11l' rlestinl'
is set: lilrt'r't1- itrrtl ,jirstit'e lor itlI."r
arrcl

\Ylrt'r'c'rts 1)r'csitlt,rrt

liill fllirrton itlso arliitrll{t'dg,eti tltt'

setrteri llroLk'nrs i,aust'tl bv the t'otttirtuirtg' legtrtlisnr rtg'airtst.\lrit'an-^\titt't'it'arrs tirat lregarr u'itll

tlee1i-

of

t'ttt:-

slar-er'1-

t'hcn he initiatetl a ttatiorral tlialog'ttt' tlltt;t-tt rtlctli

\\tereas tt

pleuuitre apologr-

first stelt irr tlie

1)i'o('ess

is tttr iutltot'tttttt

ancl ne(:eSSill'\'

of t'itcial ret'rlllt'iliiltiort;

ccrrtni'ics of ltrutal clelmrtratrization

arrd itijustices cAtttrot el'asc tlttt ltitst, but corrtbssiori of
tlre u'nrngs romr]litted r,rrrr speecl t'rtt,iztl healirrg' tittcl t'etr-

\\'het'eas

ali al)olog,1' for

onciliation antl helll Amelicarrs cottfrottt tire g'liosts of

theii' |)rrst;

\\-lrereas the legislttture of tlre t)onrurornlealth of yirg'i1ia

Iras
recentlv tal<ctt thc' lcatl in acloptillg' a rcsoh-rtion officialli.
cx1,ri'cssing' approl.n'iatc l'ei1lo1.se for. sltrvcr.r,
arrcl other

State ieg'islatnres al'e t'onsicleliirg' sinrilar r.esohitir)rls;

1r14

\\'hc|cas it is impoltarit for. tliis r:ouuti,r'. u'hir,h leg.all1. r1r(()g,!

rriz.ri slilv'l.' throug'li its corrstitutiou urul its larys, tr.r
tititl<e a firrrtrttl allolrlg'i' for slavi,i1" arrrl fir its sll(.(.essior..
,Iir, ci'ou', sti thirt it ciill ilro\'(, f'rrrr'a*l a*rl sct,l< l.ecr,riiciliation, justici., aurl htn.riionr- ibr. trll rif its citizens:
Nou,, tlier.efitr.r., lle it

1
2
3
4
5
6
7
8
9
10
11
12
i3

fir:solr:etl, That tfie lIouse of Rell.esc,tatir(

atltnou'ieclgt:s

the flnrltrrnenttrl

r'r'ueltr,, bnitalitr-, arrcl irrlruniarrit.l,

i1'justics,

of slnyes,

trrrcl

Jim Crorr;

(2)
t.rf

apolog'izes

tlre lrerplt

to Ati.icar-a,e.ic.,s o' beh,lf

,f tlre I--rritecl Slates, tirr. tlie \\,r.orlg,s

conrnrittt'tl ag'airrst tlrt,in airri tirc,ir. anct,stor.s

s,ffe.etl

.'rlc.

slrrr-t,r'r-

artr ,rirrr ('r,,u-r airtr

(ll) exlilesses its t'orurrritnrerrl

gel'ittg (tollsc(lttericcs

u.ho

of tire

1o rer,tifi-

tlte lirr-

rnistlt,crls conuuitterl

agairist -{fi'itrittt-Airr:r'ictrns uircler slaler.\, aucl ,Iirrr

t-\'0..' arrcl to stop tlre
r'ioiations irr the futni,c.

.HRES

194

o(,(,11i,r'L,rl(.e

of irunrarr r.iglrts