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Self Identification Form
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Self Identification Form
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As part of your application for employment with YWCA, please read and complete the form below!
Self Identification Form
EEO-1 Self-Identification Form; responses are used to complete the Department of Labor EEO Reporting
The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. 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 will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. We also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, Section 4212 of the Vietnam Era Veterans Readjustment Act of 1974 and Veterans Employment Opportunities Act (VEOA) of 1998. This data is for periodic government reporting and will be kept in a confidential file separate from the application for employment and employee file.
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Gender
Female
Male
Prefer not to answer
Job Title (If applicable)
Race/Ethnicity: Please select the option below corresponding to the ethnic group with which you identify
Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)
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)
Native Hawaiian or Other Pacific Islander (a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
Asian (a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
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)
I do not wish to self-identify
Veteran Status
I am not a veteran
Yes, I am a veteran
Disability- Do you have a disability?
Yes
No
Do not wish to respond
Veteran Self-Identification Form 100; responses are used to complete the required VETS-100 Reporting
Name
First
Last
Date
MM slash DD slash YYYY
Position Employed In or Applying For
Are you a veteran?
Yes
No
If yes, what is your date of discharge?
MM slash DD slash YYYY
Are you retired from the military?
Yes
No
If yes, what is your date of retirement?
MM slash DD slash YYYY
Are you a disabled veteran?
Yes
No
Are you a veteran of the Vietnam era?
Yes
No
Are you another protected veteran? (Veteran who served on active duty in the US military during a war or in a campaign or expedition for which a campaign badge is awarded)
Yes
No
Are you a recently separated veteran? (Veteran within 12 months from discharge or release from active duty)
Yes
No
Do you qualify for Veteran's Preference? (The last war for which active duty is qualifying for veteran's preference is World War II (12-7-41 thru 4-28-52)
Yes
No
If yes, please explain
Disabled Veteran means: 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 laws administered by the Department of Veterans' Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a Veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap 2‐ A person who was discharged or released from active duty because of a service‐connected disability. Veteran of the Vietnam era means: A person who: 1‐ Served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days and who was discharged or released with other than a dishonorable discharge, if any part of such active duty was performed: (A) In the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) Between August 5, 1964, and May 7, 1975, in all other cases. 2‐ Was discharged or released from active duty in the U.S. military, ground, naval or air service for a service‐connected disability if any part of such active duty was performed: (A) In the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) Between August 5, 1964, and May 7, 1975, in any other location. Other protected Veteran means: Veterans who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the U.S. Department of Defense. Recently separated Veteran means: 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. Armed Forces Service Medal Veteran means: Any Veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation to which an Armed Forces Service Medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability
Form CC-305 OMB Control Number 1250-0005 Expires 05/31/2023
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you 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: Autism, Autoimmune disorder (for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS), Blind or low vision, Cancer, Cardiovascular or heart disease, Celiac disease, Cerebral palsy, Deaf or hard of hearing, Depression or anxiety, Diabetes, Epilepsy, Gastrointestinal disorders (for example Crohn's Disease, or irritable bowel syndrome), Intellectual disability, Missing limbs or partially missing limbs, Nervous system condition (for example migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)) Psychiatric condition (for example bipolar disorder, schizophrenia, PTSD, or major depression)
Please check one of the boxes below
*
Yes. I have a disability, or have a history/record of having a disability
No. I don't have a disability, or a history/record of having a disability
I don't wish to answer
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.