EMPLOYEE SELF-IDENTIFICATION FORM
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified minorities, women, and veterans. To help us measure how well we are doing, we are asking you to tell us your race, gender, and veteran status.
Completing this form is voluntary, but we hope that you will choose to fill it out. Your answers will be kept private, and will not be used against you in any way. It is our policy to provide equal opportunity to all employees without regard to age, race, ethnicity, color, gender, the presence of a physical, mental or sensory disability, religion, national origin, sexual orientation, military status or any other category protected by local, state, or federal law.
1. Are you Hispanic or Latino/a? A person of Cuban, Mexican, Chicano/a, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Yes (Skip to question #3) No (Go to question #2)
2. What race or races do you consider yourself to be? (Check all that apply)
White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Black or African American: a person having origins in any of the black racial groups of Africa
Native Hawaiian or other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific Islands
Asian: 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:
American Indian or 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
I do not wish to Self-Identify)
3. What is your gender?
Male Female I do not wish to Self-Identify How do I know if I'm a protected veteran?
You are considered to be a protected veteran if one or more of the following categories apply:
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
A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veterans
Any 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
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.
Armed Forces Service Medal Veterans
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.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA:
I identify as one or more of the classifications of protected veteran listed above.
I am NOT a protected veteran.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
i. Executive Order 11246, as amended.
ii. Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.
For more information about 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. Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Page 1of 2 Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. 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.
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:
Multiple sclerosis (MS)
Missing limbs or
Partially missing limbs
Post-traumatic stress disorder (PTSD)
Intellectual disability (previously called mental retardation)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
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 Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Page 2 of 2 Reasonable Accommodation 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
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.