HarvardUniversity Voluntary Self-Identification Form
Name: ______Department: ______
Signature: ______Date: ______
HarvardUniversity is covered by section 503 of the Rehabilitation Act, which requires government contractors to take affirmative action to employ and advance in employment qualified individuals with disabilities, and by the Vietnam Era Veterans' Readjustment Assistance Act and the Jobs for Veterans Act, which require the same actions with respect to qualified covered veterans. Accordingly, the University has adopted affirmative action programs to provide employment opportunities for qualified disabled persons and covered veterans. If you are disabled or a covered veteran and wish to benefit under Harvard's affirmative action program, please so indicate by completing and returning this form now, or by making such a request at any time in the future.
Submission of this information is voluntary, and disclosure or refusal to provide the information will not subject you to any adverse treatment. The information provided will be used in a manner consistent with the law and will be kept confidential, except that (1) supervisors and managers may be informed regarding any work restrictions or necessary accommodations; (2) first aid or safety personnel may be informed when and to the extent appropriate to deal with any emergency treatment; and (3) government officials investigating compliance with the law may be informed.
If any of the following categories apply to you, please check the appropriate box(es) and return this form to the address below. Please contact the Office of the Assistant to the President at 617-495-4333 if you have questions.
DISABLED INDIVIDUAL
Person who (1) has a physical or mental impairment that substantially limits one or more major life activities; (2) has a record of such an impairment; or (3) is regarded as having such an impairment.
DISABLED VETERAN
Veteran of the U.S. military 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.
VETERAN OF THE VIETNAM ERA
Veteran who served on active duty in the U.S. military for more than 180 daysand was discharged or released with other than a dishonorable discharge, or who was discharged or released from active duty for a service-connected disability, if any part of such active duty occurred in Vietnam between February 28, 1961 and May 7, 1975, or in any other location between August 5, 1964 and May 7, 1975.
RECENTLY SEPARATED VETERAN
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.
ARMED FORCES SERVICE MEDAL VETERAN
Veteran who, while serving on active duty in the U.S. military, participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
OTHER PROTECTED VETERAN
Veteran who served on active duty in the U.S. military during a war or in a campaign or expedition for which a campaign badge has been authorized under laws administered by the Department of Defense.
Please return this form to Office of the Assistant to the President, HarvardUniversity,
HolyokeCenter 935, 1350 Massachusetts Ave., Cambridge, MA 02138
Revised 8/07