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ETHNICITY AND RACE IDENTIFICATION

U.S. Of6ce of Personnel Management

Guide to Personnel Data Standards

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

Social Security Number

Name (Last, First, Middle lnitial)

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. lt 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.
requires SSN be
Social Security Number (SSN) is requested under the authority of Executive order 9397, which

is
used for the purpose oi uniiorm, orderly administration of personnel records. Providing this information
provided,
however,
not
is
ssN
lf
voluntary and tailure to do so will have no effect on your employment status.

other agency sources may be used to obtain it'

@ionsbelowar-designedtoidentifyyourethnicityandrace.RegardIessofyouranswerto
Spanish culture or origin, regardlgss of race')

lJ

..-

or
Question 2. prease serect the raciar category

*tu]iE*i**ut

ll; l*-.,:r^^.i(,
t-.., xtaa
i"rt you most crosery identify by placing an

'x"

in the appropnette

box. Chec* as many as aPPIY'

DEFINITION OF CATEGORY

RACIAL CATEGORY
(Check as many as aPPIY)

pn\meric"n

America
original peoples of North and South
A oerson having origins in any of the
m m u nitv
n s tii ba I af f il atio n or co

lndian or Alaska Native

f,,flu;il'

6;iiJii*.ii* i' ;;'

;; ;;ilt

attachment.

Rsian

I
I

alack orAftican American

Far East, southeast

any of the originarp_eopres of the
A oerson having origins in
Cambodia' China' lndia'
forexamPle'
Vietnam'
Asia. or the lndian subcont'nJniin"luaing'
#i"#:i;; fiilippin" lslands' Thailand' and
Japan, Korea, Malaysia,

groups of Africa'
any of the black racial
A person having origins in
Hawaii' Guam' Samoa' or
of the original peoPles of

Pacific lslander
ttative Hawaiian or Other

in any
A person having origins
lslands'
Pacific
other

East' or
peoples of Europe' the Middle
in any of the original
origins
having
person
A
Standard Form 181
Revised August 2005

H:"":H;J";.
-.1DS tu$'lt*Tff'3utc/i*t, ^, NSN7s4*01-0ee-3446
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ETHNICITY AND RACE IDENTIFICATION

U,S, Qffice of Personnel Management

Guide to Personnel Data Standards

(Please read the Privacy Act Statement and lnstructlons before comp{eting form.)

Name (Last, First, Middle tnttiat)

HFTfuBwRV

SocialSecurity Number

rrftrrvbra\/

Agency Use Only

Birthdate (Month and Year)

--l-

\r ur F. 7-tr\ t-l

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 raie and ethn-icity 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. Office of Personnel Management or employing agency maintaining the rectrds to locate
individuals for personnel research or survey response and in the production of summary descriptive statistics and
analytical studies in support of the functlon 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 voluniary 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, qo 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.)

D Yes 'El

No

"X" in the appropriate

euestion 2. Please select the racial category or categories with which you most closely identify by placing an
box. Check as many as aPPlY.

RACIAL CATEGORY
(Check as many as aPPIY)

DEFINITION OF CATEGORY

R p"i"on having origins in any of the original peoples of No-{lt and South America
tribal afflliation or communitv
tinlfuOing Cential America), and who maintains

American lndian or Alaska Native

attachment.

tl Asian

ApersonhavingoriginsinanyoftheoriginalpeoplesoftheFar.EaSt,Southeast
nrL, o, the lnjian iubcontinent inctudin!, for.example, Cambodia, .China, lndia,
L.p?n,

fot"",

and Vietnam'
Malaysia, Pakistan' the Philippine lslands' Thailand'

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

i-f

Btack or African American

Native Hawaiian or Other Pacific lslander

ff

ramite

peoptes of Hawaii' Guam' Samoa' or

A person having origins in any of the original
other Paciflc lslands.

peoples of Europe' the Middle East' or

A person having origins in any of the originat
North Africa.

u/n**l'
Llrc--3(

rryy1ffi

ffi1u[,n*j't-epru:k^:;-trh

Standard Form 181

Revised August 2005
usal
Previous editions not usable
)0e-1 6
42 U.S.C. Section 2000e'

NSN 7540-01-099-3446

x * rr Communication Result

P1
Report(Jan.15,2016 6r32PM)x
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Date/Iime: Jan.15, 2016

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2051 Menrory

TX

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U.S. Omce of FersonnelManagement

Guide to Personnel Data Standards

ETHNICITY AND RACE IDENTIFICATION

(Please read the Privaoy Aot Statement and instructions before completing form.)

Nama (Last, Firsl. Middle lnitial)

Social Security Number

Eil

Tlr4DA.Ar[,v"i-cml?. n
Agency
Use Only

Birthdate (Month and Year)

Drrpmhrr H+V

Privacy Act Statement

Ethnjgi-ty 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 Dita 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 thls 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. Regardl,ess of your answer to
question l, go to question 2.
Question l. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Cet ltral American, or other
culiure or origin, regardless of race.)
Spanish
'

ilYes M ruo

"X" in the apProPriate

egories with which you most closely identfu by pla cing an
RACIAL CATEGORY
(Check as many as aPPIY)

nmerican Indian or Alaska Native

DEFINITION OF CATEGO

peoples oT Nonn alru ouuur

A person having origins in any of the onglnal
-mainiains tribal affiliation or communitv
Ceniat Americ"J, and who

iirlfrOlrg

attachment.

Far..East' Southeast

Asian

Black or African American

tlative Hawaiian or Other Pacific lslander

l,{*n,*

l-

peoples of the
A person having ongins in any of the original
example' Cambodia' China' lndia'
for
Asia, or the lndian ,uO"ont'#nt includin['
rhailand' and vietnam'
fjo]", k;;;;;utaiavsia, p'ititt'"' the Philiipine lslands'
black racial groups of Africa'
A person having origins in any of the

Samoa' or
the original peoples of Hawaii' Guam'
A oerson having origins in any of
other Pacific lslands'
the Middle East' or
of the original peoples of Europe'
A person having origins in any
North Africa.
Standard Form

l6

Revised August 2005

Previous editions not usable

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

NSN 790-01-09s-3446

A6/2012016 18:59 FAx 7205357050

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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, Middte tnitiat)

Social Security Number

Privacy Act Statement

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance
with
O_ffice 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 rale anO etnnicity by visual observation.

the

This information is used as necessary to plan for equal employment opportunity throughout the Federal government. lt
is also used by the U. S. Office of Personnel Management or empioying agency riaintaining the reiords to locate
-summary
individuals for personnel research or survey response and in the produition of
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 g3g7, 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. 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.
Question

1.

Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other

Spanish culture or origin, regrdless of race.)

J ves tfio

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 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
atiachment.

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'
Black or African American

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

Native Hawaiian or Other Pacific lslander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific lslands.
East' or
A person having origins in any of the original peoples of Europe, the Middle
North Africa.
Standard Form 181
Revised August 2005
Previous editions not usable
42 U.S.C. Section 2000e-16
NSN 7540-01-099-3446

HI.]FFPOST RELIGION
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Pope Apologizes For Catholic Ghurch's

'Offienses' Against lndigenous Peoples
"l humbly ask forgiveness...for crimes committed against the native peoples
during the so-called conquest of America."
O

ozioelzors 07:54 pm ET I updated Jul

43 ! **,"

'10,

2015

w,nnetd, Ja@bo carcia

IIYATCH: Pope Francis Apologizes For Church's'Grave

Sins'

{
FOTLOW HUFFPOST

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HUFFPOST NEWSLETTERS
storis 4d blog p6b smaild to me Ech day.
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adrthemals. Lqm i'bre.

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address@etnoil.com
Pope Francis apologized Thursday forthe sins and
peoples during the
"offenses" committed by the catholic church against indigenous
colonial-era conquest of the Americas.
SANTA CRUZ, tsolivia

subssibel

(AP)*

Histoqfs first Latin Americen pope'humbly" begged forgiveness during an

in the presence
encounter in Bolivia with indigenous groups and other activists and
of Bolivia's first-ever indigenous president, Evo Morales'
Francis noted that Latin Arnerican church leaders in the past had ac*nowledged
of
"grave sins were commitGd against the native pop[es of America in the name
forthe
God." st. John Paul ll, for his par! apologized to the continents indigenous

"painandsufiering,causedduringtheS00yearsofthechurcfi'spreseneonthe
continent during a 1992 visit to the Dominican Republic'

SUGGESTED FOR YOU

.l

Rev. Jim Wallis: Racism'Seoarates

But Francis went fartner.

"! humbiy as( forgiveness. not oniy for the orlenses
of ths church herseii. i:ut aisc
for crimcs committed agaiilst the native peopres ciirring
the so-calied conquest of
Ar'l-'rol,ice." he seiC t0 Epplsuse snd cheers from
tne crowd.
Eariie:: in the day, Flancis denauilced the "thfowaway', culrure
of today,s socrety tnat
discarcs anyone who !s unpr'celuciive as r.re ceierri"ated l.:is first pubiic
rr,4ass in
Bo!i'rla.

The governrnent deciareci a naticnal l}oiiday so v+orkers

and str,;derrts caulij attend
the l"4ass. which ieatured prayer"s in Gu=rani and Aimara,
*l,o ci Borir,!a,s
indigenous languages" and an aitar caryed fr-om ,.,:oori by
ar1lsans cf the chiquiianc

pecpie.

ln e blending ef the natir.,e and new. t!'re fanrously unpretenticllls p+p:e

chapged into
his vestments fcr. the l.rlass in a nearbyr Fur-ger i(inE.

speaking to the croivd in south America's po.3r-esi country. Francis decrieci

ti:e
prevaiiing meniality of the wor'ld econo{r.!/ wl:ere so many Deople are ,'cJiscarderi,'
icCay

the peor. the eiderly. thcse whe are unproductive.

"lt is a mentelity in r,vhich everytiring has a price. ever,vflring can be boirci-ri=

everytning is negotialrie." he saicj. "Ti.,is way of tl.rirrFling has iocni cnlli fcr a selecl
fey,'. whiie it discards all those who are unproductive.,,
l-:e overshadowed by piesident Evo lr4craies'
coniroversiai girt to Francis upon his errivai: a cruci{ix carved lnto a hamrner and

Tne cay. however. threatened to

sickie.

Boih the Vatican and the Boiivian governmellt ilsisled L,lorales wasn't makit-rg a
hereticai or poiiticai statement with ihe gift. They said the crcss. liubL'ed ihe
"Communist cr-,.Lcifix." haci originally been designed by a Jesuit aetir;ist' the Rev'
Lurs Espir:ai, wtro was a$sassinated in 1$80 by suspecteci paranrilitaries durinS; ilre
rncnths that piececied a vioient miliiary* cotip ln Bolivia. On Wednesday. Francis. a
feliow iesuit. prayed at the site rshere Espinal's bcdv was dumped.

You can dispute the significanee and use of the symbol now, but the origin is from
Espinal and the sense of it was abaut an open diarogue, not about a specific
ideology," said the vatican spokesman, the Rev. Federico Lombardi.

The Bolivien govemment insisted the glft wesnl a political meneuver

0f any sort, Dut
was a profound symbol that Morales thought the "pope of the poor" would
appreciate.
"That was the intention of this gift, and it was not any sort of maneuver
... lt was
really from great affection, a work designed by the very hands of Luis Espinar,"

Communications Minister Marianela paco told patria Nueva radio.

Associated Press writers Paola Flores and carlos valdez contributed.

Atsa an HultPast:

mORE;

pope Francis's lrlost Prophetic State...

HlBion, GrdEllcotnrch, Popefref,cis, Pofte, Poff Afolo{,f , lndigie*o4 Peopic, Co{soarlisr

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I{. Res. 194

In, the Hoa*e of Representa,tiues, (/. S.,

Jal,y 29, 20A8.

Whereas millions of Africans and their descendants were

enslaved in the Ilnited. States and the LB Ameriean coionies fr"om 1619 through 1865;
Whereas slavery in A"rneriea resembled no oiher form of invol-

untary servitude lerown in history, as Africans were captured and solcl at auetion like inanimate objeets or animals;
Whereas Aftieans forced into slavery were brrrtalizecl, humiliated, clehumanized, ar,rd subjected to the incligntty of

being stripped of iheir names and heritage;

Whereas enslaved. families were torn apart after having been
sold separatelY from one another;
whereas the system of slavery ancl the vrsceral racism against
persons of African clescent upon whieh it clepenclecl became entrenchecl in the Nation's social fabrie;
passage
l[Ihereas siavery was not offreially abolisherl untii the
of the 13th Amenclment to the united states constitution in 1865 after the encl of the Civil War;

slavery' AftiWhereas affer ernancipation from 246 years of

social, antl
can-Americans soon saw the fleeting political,

eeonomicgainstlieymad'ecluringE'econstructionevisceratedbyvimlentrIlcism,lynchings'drsenfuanchisement'

Blacir Codes, and racial segregation laws that imposed. a

rigid s;,s1sm of officially sanctionecl racial segregation in
virtually all areas of life;

the system of de jure racial segregation known as

"Jim Crow," which arose in certain parts of the Nation
following the Civil \Yar to ereate separate ancl unequal
societies for whites and Afriean-Americans, lyas a direct
result of the racism against persons of African deseent

trtr4rereas

engenclered by siavery;

Whereas a century after the officiat end of slavery in A:ner-

iea, Federal action was required during the 1960s to

eliminate the dejure and defaeto system of Jim Crow
throug'hout parts of the Nation, though its vestiges stili
linger to this clay;

to suffer from the

plex interplay between slavery and Jim Crorr-long

Whereas African-Americans continue

comafber

both systems lyere formally abolished-thr"ough enormous

rlamage and loss, both tangible and intangible, including
tire loss of huma* dignity, the fmstration of careers and
professional lives, and- the long-term loss of income and
opportunity;
Whereas the story of the enslavement and de jure segregatioir
of African-Amerisans and the clelurmanizing atrocities

committed against them shouid not be purged from or

minimizecl in the telling of American history;
\\'Ihereas on July 8, 2003, cluring a

trip to Goree Isiancl,

Sen-

"W.

Bush acegal, a forrner slave port, Presiclent George

hnowleclged" slavery's continuing legacy iu American life
and th.e nee,l to confront that legacy when he stated that
slavery "1vas one of the greatest crimes of history

. ,' . Tire racial i:igntry feci by

.EBES 194 EE

slavery clicl not end with

slaveiy or with segregation. And manJr of the issues trrat

sti]l troul:le Amer"ica have roots in the bitter erperienee
of other times. But hor,rrever long the journey, our destiny
is set: Iiberiy and jr:stice for ail.,,;
'l1hereas
President Bilt clinton al.so aeknowledged the cleepseatecl problems *ansed by the continui*g legacy of rac-

ism against Afriean-Ameriear:s that began with slavery

when he initiatecl a national dialogne about race;

Wl:ere$s

genuine apolog;, is an important and necessary

first step in the process r:f racial reconciliation;
"wllereas
au apology for centrrries of bnrtal dehurnanization
and iqjustices caru1ot erase the past, but confe,ssion of
the wrongs committed can speed racial heaJing and reconciliation and help Americans conftont the ghosts of
their past;
IErereas the ieg{slature of the Commonwealth of Ylrginia has
reeentl;r taken the lead in adoi:ting a resolution officialty
expressing appropriate remorse for slavery ancl other
State legislatures have ad,opted or are considering similar
resolutions; alld
l,,Vhereas

it

is important for this eountry, which legally recognlzecl slavery throug'h its Constitution ancl its laws, to
make a formal apology for slaverXt and for

Jim Craw, so thai

iis

$uccessor,

it

can moys forward and seek reconciliation, justice, anrl harmony for all of its citizens:
Now, thercfore, be
Resol;ued,

it

That the Houce of Eeprese::.tatives-

i1) acknornrieclges that slar.ery is incornpatilile with

the hasie founding principles recognized in the Deslaration of Independence that aii men are crea,ted equal;
TIIE.ES 194 EH

(?] aeknowiedges the fuildarneatal *linxtiee; er*el{y;

bnrtality, anrl ir:foumariiry of sla,very *nd Ji,nr,flrotr;
{S) apologises to Africaq A:r.reriee,ns an'hehalf o{ the
peopla of ths

llnitod States, forr the

agsfu]st them &ad

rnrra$gs eemmitted

their arieestoie who suffered under

slavery,and Jim Cro.rv; and

(4)

exprssss

its

ga]"Jrr$ consegueneee

eonrmitment

to rectify fte

tin"

of ih* misd*eds committed againat

A-frican Amerieans und^er slavery and

Jim

Ch'ow aird to

stop the oceurrence of human rights violations in the fu-

hre.
Attestu

Abrh,

rffiEB Xg4'SI{