Federal laws and regulations require us to report on our workforce by race, gender, and veteran status and to offer the opportunity for self-identification as to disabilities. Please assist us by completing this form. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Data which you provide shall be kept strictly confidential, except that (i) supervisors and managers may be Informed regarding restrictions on the work or duties of disabled individuals and/or disabled veterans; (ii) first aid and safety personnel may be informed, to the extent appropriate, if the condition might require emergency treatment; and (iii) governmental officials reviewing the Company's compliance status shall be informed.
Social Security Number
Race/Ethnicity: Please check one.
Hispanic or Latino
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
American Indian or Alaska Native (Not Hispanic or Latino)
White (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)
Veteran Status: Check all that apply.
I am a disabled veteran *
I a recently separated veteran *
I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized
I participated in a United States military operation for which an Armed Forces Service Medal was awarded, while serving on active duty in the Armed Forces, pursuant to Executive Order No. 12985 (61 Fed. Reg. 1209).
Date of Discharge
I am an individual with a disability
I have received the form and decline to provide the requested information
SELF-IDENTIFICATION FORM DEFINITIONS
1. The term ''Disabled Veteran'' means -
A. a veteran 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 Department of Veterans Affairs for a disability; or
B. a person who was discharged or released from active duty because of a service-connected disability,
2. The term "Recently Separated Veteran" applies to any veteran during the three-year period beginning on the date of discharge or release from active duty.
3. An "individual with a disability" means any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (ii) has a record of such impairment: or (iii) is regarded as having such impairment.