SUPPLEMENTAL QUESTIONS FORM
EAST BAY MUNICIPAL UTILITY DISTRICT
Diversity and Inclusion Office
375 ELEVENTH STREET, MS601
OAKLAND, CA 94607-4240
(510) 287-0710 FAX NO. (510) 287-0673
All qualified candidates are considered without regard to race, color, religious creed, national origin, ancestry, age, physical or mental disability, medical condition, genetic information, marital or domestic partnership status, sexual orientation, military or veterans status, pregnancy, family or medical leave status, or any other status protected by state and federal laws.
IMPORTANT NOTICE: This form is being distributed by EBMUD to gather information relevant to the internship program. This information must be gathered by EBMUD for confidentiality reasons. Completing this form does not imply that that you are applyingfor a job or being considered for a job with EBMUD.Selection into the IM Internship Program DOES NOT GUARANTEEfuture employment at EBMUD.
YOUR NAME (please print) / Other names under which you have worked:
Last / First / Middle
YOUR MAILING ADDRESS
Number / Street / Apt. No.
City / State / -
Zip
CONTACT INFORMATION
Home phone () - / Message phone () -
Work phone () -Extension: / E-mail
POSITION FOR WHICH YOU ARE APPLYING:
IM Intern at EBMUD through Laney College Coop Ed Program
Have you previously worked as an intern (paid or unpaid) at EBMUD?YESNO
Have you worked previously for EBMUD?YES NO
Do you have any relatives who are EBMUD employees?YESNO
DO YOU HAVE A VALID DRIVER’S LICENSE? / YES / NO
DRIVER’S LICENSE NO. / CA / OTHER
CLASS ACLASS BCLASS C (AUTO ONLY)
ENDORSEMENTS
RESTRICTIONS
HAS YOUR LICENSE BEEN REVOKED OR SUSPENDED IN THE PAST FIVE YEARS? / YES / NO
HAVE YOU BEEN SUBJECT TO FORMAL DISCIPLINARY ACTION AT A JOB WITHIN THE LAST 12 MONTHS? / YES / NO
Referral Source
I learned of this IM Internship opportunity through the following source(s) check all that apply:
Diversity and Inclusion Office
Bulletin Board
Career or Job Fair
Community Agency
EBMUD Website
Employee
Job Hotline
Newsletter or Journal
Newspaper
Recruitment Letter
Walk-in
Website (i.e. Monster, Craigslist, Yahoo, etc)
Announcement at Meeting (please specify)
School (please specify)
Other (please specify)
The purpose of the following questions is to obtain additional statistical information needed to evaluate EBMUD’s internship program, as well as to prepare statistical reports required by Federal, State, and local agencies. Submission of this information is voluntary and refusal to provide it will NOT subject you to any adverse treatment. The information will be kept confidential and separate from the information above and your resume and other materials submitted.Voluntary Self-Identificationof Gender
MALE
FEMALE
DECLINE TO STATE
Voluntary Self-Identificationof Race/Ethnicity
The definitions for each category have been established by the federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below. Please mark the one box that describes the race/ethnicity category with which you primarily identify.
Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
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.
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.
Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples ofHawaii, Guam, Samoa, or other Pacific Islands.
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 tribal affiliation or community attachment.
Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity categories.
Decline to state
Voluntary Self-Identificationof Disability
IMPORTANT NOTICE: This form is prescribed by the Department of Labor’s Office of Federal Contract Compliance and cannot be altered. Any references to “hire” or “applying for a job” on this form DOES NOT imply that you have applied for a job with EBMUD. This form is simply being distributed by EBMUD to gather information relevant to the internship program for statisticalreasons. The information collected from this form will be kept confidential and separate from your resume and other submitted materials for the IM Internship Program opportunity through Laney College Cooperative Education Program. Selection into the IM Internship DOES NOT GUARANTEEfuture employment at EBMUD.
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 1
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.
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:
- Blindness
- Autism
- Bipolar disorder
- Post-traumatic stress disorder (PTSD)
- Deafness
- Cerebral palsy
- Major depression
- Obsessive compulsive disorder
- Cancer
- HIV/AIDS
- Multiple sclerosis (MS)
- Impairments requiring the use of a wheelchair
- Diabetes
- Epilepsy
- Schizophrenia
- 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 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.
______
1 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.
Voluntary Self-Identificationof Protected Veterans Status
EBMUD is 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), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:
- A “disabled veteran”is oneof thefollowing:
- a veteran of theU.S.military,ground, naval orairservice who isentitled to compensation (orwho but forthereceipt of militaryretiredpaywould beentitled to compensation) underlawsadministeredbythe Secretaryof Veterans Affairs; or
- aperson whowasdischarged or released fromactive dutybecauseofa service-connecteddisability.
- A “recentlyseparated veteran” means anyveteranduringthethree-year periodbeginningon the date ofsuch veteran’s dischargeorrelease fromactive dutyin theU.S.military,ground,naval, or air service.
- An “active dutywartimeor campaign badgeveteran” means aveteran whoserved on activedutyin theU.S. military,ground,naval orair service duringawar, orin acampaignorexpedition for which a campaign badgehas beenauthorized under thelaws administeredbythe Department of Defense.
- An “Armedforces service medal veteran” meansa veteran who,while servingon active dutyin theU.S.military,ground, navalor air service, participatedina UnitedStatesmilitaryoperationfor whichanArmedForcesservice medalwasawarded pursuant toExecutive Order12985.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.
We request this information in order tomeasuretheeffectiveness of the outreachand positive recruitmenteffortsweundertake for our IM internship.
IIDENTIFY ASONEOR MORE OFTHE CLASSIFICATIONS OFPROTECTED VETERANLISTED ABOVE
IAM NOT A PROTECTED VETERAN
DECLINE TO STATE