Affirmative Action Questionnaire

Government agencies require reports on status of applicants including gender, race, ethnicity, veteran status and disabilities. This data is for analysis and affirmative action only. Submission is voluntary. Failure to supply this information will not jeopardize or adversely affect any consideration you may receive for employment or later advancement in employment.

Do you wish to provide this information?

Yes No

If you choose to continue, please select the options in each section below that best match your profile.

Gender

Male Female

Disability

Yes No

Disabled Individual (Mental or Physical) - A person who has a mental or physical impairment that substantially limits one or more major life activities, who has a record of such impairment, or who is regarded as having such impairment.

Race/Ethnicity

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) – 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 (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.

Veteran Status

Veteran Non-Veteran

If a Veteran, please identify which status is most applicable to your situation:

Disabled Veteran - (1) 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 the laws administered by the Secretary of Veterans Affairs, OR (2) A person who was discharged or released from active duty because of service-oriented disability.

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, ground, naval or air service. (See Date Discharged box below)

Vietnam Era Veteran - A Vietnam era veteran is a person who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge; (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975; or (3) served on active duty for more than 180 days and served in the Republic of Vietnam between February 28, 1961 and May 7, 1975.

Other Protected Veteran - A veteran who served on active duty in the U.S. military, ground, naval or air service, under the laws administered by the Department of Defense.

None

Date Discharged, if Recently Separated Veteran

Contact

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Gender

Disability

Race/Ethnicity

Veteran Status

Contact

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