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Position you are applying for:
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This company prepares affirmative action plans that cover females, minorities, protected veterans, and individuals with disabilities. This survey is meant to help the company fulfill various objectives in these affirmative action plans.
PLEASE NOTE: You are not required to complete any part of this form.
Submission of this form is voluntary. The decision not to complete this form will not affect any opportunity for employment or any benefits with the company. Any information you provide in this survey will be kept confidential and will not be used in any way that may adversely affect your employment with this company.
Affirmative Action Related Data
(Please check appropriate boxes)
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Hispanic (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Decline to Answer
(If you checked "Not Hispanic" above, please check one or more of the boxes below.)
Asian/Indian Subcontinent (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
Black/African American (A person having origins in any of the Black racial groups of Africa.)
Native American/Alaskan Native (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.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
Decline to Answer
If you believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate box. As a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
I belong to one or more of the classifications of protected veterans listed below.
I am a veteran, but do not fall into one of the classifications listed below.
I am not a veteran.
Decline to Answer.
Protected Veteran Categories:
- A disabled veteran is one of the following: (a) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs or (b) a person who was discharged or released from active duty because of a service connected disability.>
Recently Separated Veteran
- A recently separated veteran is a veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.>
Active Duty Wartime Or Campaign Badge Veteran
- An active duty wartime or campaign badge veteran is a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense. (Note: The term “Active Duty Wartime Veteran” includes, but is not limited to, a veteran who served any time between 8/5/64 and 5/7/75, any time between 8/2/90 and the present day, as well as during various military conflicts defined as qualifying events by the Department of Defense.)>
Armed Forces Service Medal Veteran
- An armed forces service medal veteran is a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.>
Voluntary Self-Identification of Disability
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.>
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.>
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. >
Disabilities include, but are not limited to: >
• Bipolar disorder>
• Post-traumatic stress disorder (PTSD)>
• Cerebral palsy>
• Major depression>
• Obsessive compulsive disorder>
• Multiple sclerosis (MS)>
• Impairments requiring the use of a wheelchair>
• Muscular dystrophy>
• Missing limbs or partially missing limbs>
• Intellectual disability (previously called mental retardation)>
Please check one of the boxes below:
Yes, I have a disability (or previously had a disability).
No, I don't have a disability.
I don't wish to answer.
Reasonable Accommodations Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i. Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.>
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.>