Personnel Intake Form

As noted by the Schusterman Family Philanthropies, “Data collection must be intentional, inclusive and equitable. How an organization collects data reflects its values, by either perpetuating bias and inequity or promoting inclusion and equity.” This form is a guide for what government could do to ensure intentional and equitable data collection.

First Name*

Middle Name

Last Name*

Your Personal Email Address*

Phone Number*U.S. phone numbers must be 10 digits without any special characters.

Address*

Address Line 2

City*

State / Territory*

Zip Code

Country

If you are currently employed, what is the name of your employer?

What is your current title?*

Are you a U.S. Citizen?*

If you are not a U.S. Citizen, are you eligible to work in the United States?*

Are you a Veteran of the U.S. Armed Forces?*

Are you currently employed by the Federal government?*

Do you have past government experience? If so, please select all that apply.*

Please briefly describe your previous government experience if applicable.

Have you ever served and/or do you currently serve on any Boards? If yes, please list the names of organizations and dates of service.

I would be willing to serve as (check all that apply):*

Desired Functions*

Desired Policy Areas of Interest*

Desired Department / Agency / Board / Commission*

Are you a registered federal lobbyist or have you been a registered federal lobbyist in the past 24 months?*

__Demographic Information

What is your race and/or ethnicity? You may choose more than one.

What are your pronouns?

Which of the following best describes your gender identity?

If you chose “another gender,” how would you best describe your gender identity?

What is your sexual orientation?

If you chose “another orientation,” what is your orientation?

Do you identify as a person with a disability?

What accommodations, if any, do you need to fully participate in activities successfully?

Are you the first in your family to attend college?

Are you the child of immigrants or do you consider yourself to be a first-generation American?

Which of the following best describes your religious affiliations? (Select all that apply)

Do you identify with other communities that have historically been under-represented in government? (e.g., religious minorities) If so, please list below:

What is your Date of Birth?

What is your U.S. geographic affiliation? (What do you consider your home state to be?)

Marital Status

What is your political party?

Have you ever managed people before? If so, how many?

Have you ever managed a budget for an organization before? If so, how much?

Please describe your management experience, if any:

Please describe any additional qualifications:

Please describe why you hope to be a part of this organization:

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Resources

More than Numbers: A Guide Toward Diversity, Equity, and Inclusion (DEI) in Data Collection (Charles and Lynn Schusterman Family Philanthropies)
Rethinking and Updating Demographic Questions: Guidance to Improve Descriptions of Research Samples (Jennifer L. Hughes, Abigail A. Camden, and Tenzin Yangchen – Agnes Scott College)
Driving Equity With Demographic Data Collection (PEAK Grantmaking)