EmployeeVoluntaryQuestionnaireforSelf-Identificationof:Race/Ethnicity,DisabilityandVeteranStatus
Employee’s Name:Date: Employee ID # (your human resource or payroll representative can provide this number): Gender: Female Male
Completingthisquestionnaireisoptional;ifyoudo notprovidethisinformationitwillnotsubjecttoanyadversetreatment.
Section1dataiscollectedasrequiredbytheEqualEmploymentOpportunityCommission.TheDepartmentof AdministrativeServicessubmitsthestatewidedatainabiennialreporttotheEqualEmploymentOpportunityCommission (EEOC).Datainallsectionsisusedforstatisticalandreportingpurposes.Theinformationmaybesubjecttodisclosure underfederalor state law or rule.
Anti-Discrimination Notice
Itisanunlawfulemploymentpracticeforanemployertofailorrefusetohireordischargeanyindividual,orotherwise
discriminateagainstanindividualwithrespecttotheindividual’stermsandconditionsofemployment,becauseofan individual’srace, color,religion, sex, nationalorigin, disabilityor veteran status.
Section I. Race/Ethnicity*
Your employerisrequired to record and reportcertainnondiscrimination andaffirmative actionstatistics.The stateinvites
employeestovoluntarilyself-identifytheirrace/ethnicity.Thisinformationwillbeusedaccordingtotheprovisionsof applicablefederallaws,executiveordersandregulations,includingthoserequiringtheinformationtobesummarizedand reportedtothefederalgovernmentforcivilrightsenforcementpurposes.Allrace/ethnicityinformationiscollectedand reported in five EEO-4 categories:(A) Asian orPacific Islander, (B) Black, (H) Hispanic,(I) American Indian orAlaskan Native, (W)White,established bythefederalgovernment.
Ifyou chooseto voluntarilyself-identify, please markthe one box describingthe race/ethnicitywith which you identify:
(A)Asian or Pacific Islander:Allpersons having originsin anyof thepeoplesof the Far East, Southeast Asia,
theIndiansubcontinent,orthePacificIslands.Thisareaincludes,forexample,China,Japan, Korea,thePhilippine Islandsand Samoa.
(AB) Asian or Pacific Islander, Black
(AH) Asian or Pacific Islander, Hispanic
(AI)Asian orPacific Islander, American Indian orAlaskan Native
(AW)Asianor Pacific Islander,White
(B) Black(notof Hispanicorigin): Allpersonshavingorigins inanyof the Blackracialgroupsof Africa.
(BA) Black, Asian or Pacific Islander
(BH) Black, Hispanic
(BI) Black, AmericanIndian orAlaskan Native
(BW)Black, White
(H) Hispanic:Allpersons ofMexican, Puerto Rican, Cuban, Centralor SouthAmerican, orotherSpanishculture or origin,regardless of race.
(HA) Hispanic, Asian orPacificIslander
(HB) Hispanic, Black
(HI) Hispanic, American Indianor Alaskan Native
(HW)Hispanic, White
(I)American Indian orAlaskan Native:Allpersons havingoriginsin anyof the originalpeoplesof North America, and whomaintainculturalidentification through tribalaffiliation or communityrecognition.
(IA) American Indian or Alaskan Native, Asian or Pacific Islander
(IB) American Indian or Black
(IH) American Indian, Hispanic
(IW) American Indian, White
(W) White(notof Hispanicorigin): Allpersonshavingorigins inanyof the originalpeoples ofEurope, North Africa orthe Middle East
(WA)White, Asian or Pacific Islander
(WB)White,Black
(WH)White, Hispanic
(WI) White, American Indian
*Ifyou choose notto self-identify your race/ethnicity,thefederalgovernmentrequires the employerto determine this information by visualsurveyand/or other availableinformation.
ForagencyHRuseonly:
AV(Asian orPacific Islander-Visualassessment)
BV(Black-Visualassessment)
HV(Hispanic-Visualassessment)
IV (American Indian or Alaskan Native-Visualassessment)
WV(White-Visualassessment)
Manager name and signature ______
Section II: **DisabilityYes
No
(Anyrequestsforaccommodation for acurrentor future disabilitymustgo through your supervisorand human resources.)
Section III:**Are you aVeteran of the United StatesMilitary ArmedForces YesNo
(Declaring you are a veteran onthisformdoes notsatisfy your obligationto declare veteranstatusinfuture employment
applications,if you wish toreceive veteran’s preference points.)
**Providingthisinformation is voluntary.
This formmay bedestroyed aftertheinformation on thisformis enteredintothe PersonnelData Base.