Information for Federal and State Reporting Purposes
Name
Position Applied For
The college is required by law to report the composition of its employment force to the government. The form allows individuals to self-identify their ethnicity and race and to select more than one race and/or ethnicity. This allows individuals to more accurately reflect their racial and ethnic background by not limiting them to only one racial or ethnic category. Clarifying definitions are provided on the back of this form. Your voluntary cooperation will be appreciated. The information on this form will be filed separately from the main application form and will not be accessible to those processing your application. Safeguards are used to prevent the discriminatory abuse of this information. It will be available only to the person responsible for government reporting purposes.
Are you Hispanic or Latino?
No, not Hispanic or Latino (999) Yes, Hispanic or Latino. If “yes”, choose one:
Mexican, Mexican American, Chicano (722)
Puerto Rican (727)
Cuban (709)
Other Hispanic or Latino –Please specify:
The question above is about ethnicity, not race. If you marked “No, not Hispanic or Latino,”please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.
What is your race? (Choose one or more)
Black or African American (870)
Caucasian/White (800)
American Indian or Alaska Native
American Indian (597) - Please specify the tribe: Aleut (941)
Other Native American – Please specify: Eskimo (935)
Asian
Chinese (605) Filipino (608) Korean (612) Vietnamese (619)
Cambodian (604) Japanese (611) Laotian (613) Other Asian - Please specify:
Native Hawaiian or Other Pacific Islander
Native Hawaiian (653)Pacific Islander - Please specify:
VETERAN STATUS: Are you a veteran of the U.S. armed forces? Yes No
If YES, please check one of the following:
Disabled Veteran/Vietnam-era (DV) Vietnam-era Veteran (VV) Spouse of Disabled Veteran (SV)
Other Veteran (OV) Disabled Veteran (DO)
GENDER: Male FemaleAGE: Are you age 40 or over? Yes No
DISABILITY STATUS: Do you have a physical, sensory, or mental impairment which substantially limits one or more life activities?
Yes No If YES, please check one of the following:
Ambulatory/Mobility (1) Mental/psychological (4)
Visual (2) Multiple disabilities (5)
Hearing (3) Other (9)
Do you have a physical, mental, or health condition that has lasted six or more months which limits the kind or amount of work you can do at a job? Yes No
Disabilities. For Affirmative Action purposes, people with disabilities are persons with a permanent physical, mental or sensory impairment which substantially limits one or more major life activities. Physical, mental or sensory impairment means: (a) any physiological or neurological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems or functions; or (b) any mental or psychological disorders such as mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The impairment must be material rather than slight, and permanent in that it is seldom fully corrected by medical replacement, therapy or surgical means.
REFERRAL INFORMATION: How did you find out about this opening?
Walk-In Newspaper - Print name:Other - Please specify:
Announcement Public Agency - Print name:
Friend Internet - Please specify site:
Signature of Applicant Date
THIS SUPPLEMENTAL INFORMATION IS FOR RECORDKEEPING ONLY
Caucasian/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.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
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 Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains cultural identification through 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.
What are the ethnicity and race categories?
Ethnicity: The first part of the two-part question asks whether or not the respondent is Hispanic or Latino.
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race.
Race: The second part asks the respondent to select one or more races from the following five racial groups:
American Indian or Alaska Native: A person having origins in any of the original peoples of North and
South America (including Central America), and who maintains a tribal affiliation or community attachment.
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.
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,
Samoa or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
How will the information be used?
The data with the new ethnicity/race categories will be used in the same manner that racial/ethnic data are currently used. The new categories will replace the existing categories for use in all state and federally sponsored statistical data collections that include data on ethnicity or race, such as affirmative action reports. State and local guidelines are in place to ensure that racial and ethnic data will not be reported elsewhere in a way that an individual may be identified. The college follows FERPA rules and regulations to safeguard the privacy of student records and, for employment records; none of the equal employment opportunity rules has changed. Your race and ethnicity will not be used to determine your employment status or condition.
Where can I find more information?
More information is available on the government website:
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