Fillable AFFIRMATIVE ACTION OFFICE (Lake Superior State University)

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AFFIRMATIVE ACTION OFFICE (Lake Superior State University)

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U.S.A. forms for Lake Superior State University

BROWSE LAKE SUPERIOR STATE UNIVERSITY FORMS

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AFFIRMATIVE ACTION OFFICE
CONFIDENTIAL – EQUAL EMPLOYMENT OPPORTUNITY STATISTICAL FORM
Lake Superior State University is subject to Federal, State and University laws and regulations governing
Affirmative Action and Equal Employment Opportunity and does not discriminate on the basis of race,
color, national origin or ancestry, gender, sexual preference, age, disability, religion, height, weight,
marital status, or veteran status.
As a State institution and beneficiary of state and federal funds for operation, LSSU is required to furnish
a variety of annual government reports. In order to insure the accuracy of these reports, we ask that you
assist us by completing the information below. This information will only be used for reporting as
required by government agencies. Although completion of this form is optional, your reply is greatly
appreciated.
This information will not in any way be used for employment decisions, and will not be seen by those
making hiring decisions.
DATE: _______________________ NAME: ___________________________________
SEX: Male ________ Female __________ TITLE OF POSITION: _________________
ETHNIC BACKGROUND (check whichever applies)
*Please read descriptions on the reverse side
_____ Black (not of Hispanic origin)
_____ Asian or Pacific Islander
_____ Hispanic (including Mexican, Central or South American, or other Spanish Culture)
_____ White (including Caucasian, European, North African, Middle Eastern-not Hispanic)
_____ American Indian or Alaskan Native
_____ Foreign National (all persons who are not either U.S. Citizens or permanent U.S.
residents) [specify _________________________]
_____ Multiracial (having parents of different races)
OTHER SELF-INDENTIFICATION (check all that apply)
*Please read descriptions on the reverse side
_____ Vietnam Era Veteran _____ Disabled Veteran
_____ Temporarily Disabled _____ Disabled
_____ Age 40 to 70
SIGNATURE ________________________________________
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*SELF-IDENTIFICATION DESCRIPTIONS
Use the following classifications to identify yourself
RACE/ETHNIC:
1. BLACK (not of Hispanic origin): All persons having origins in any of the Black racial groups.
2. ASIAN or PACIFIC ISLANDERS: All persons having origins in any of the original peoples
of the Far East, Southeast Asia, or the Pacific Islands. This area includes Chins, Japan, Korea,
the Philippine Islands, Samoa, and the Indian Subcontinent.
3. HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or
other Spanish culture or origin, regardless of race.
4. WHITE (not Hispanic origin): All persons having origins in any of the original peoples of
Europe, North Africa and the Middle East.
5. AMERICAN INDIAN or ALASKAN NATIVE: Persons having origins in any of the original
peoples of North America and maintaining cultural identification through tribal affiliation or
community recognition.
VIETNAM-ERA VETERAN:
If you served on active duty for the period beginning on February 28, 1961, and ending on May
7, 1975, in the case of a veteran who served in the Republic of Vietnam during that period; or the
period beginning on August 5, 1964, and ending on May 7, 1975, in all other cases; and were
discharged or released from that duty prior to December 31, 1991, with other than a dishonorable
discharge.
DISABLED VETERAN:
1. If you are entitled to disability compensation administered by the Veterans Administration for
a disability rated at 30% or more, or
2. If you were released or discharged from active duty for a disability incurred or aggravated in
the line of duty.
DISABLED:
1. If you have an impairment (physical or mental) that substantially limits one or more of your
major life activities. (A major life activity is any mental or physical function that, if impaired,
creates a substantial barrier to employment.)
2. If you have a record of such an impairment as noted in #1 above.
3. If you are regarded as having such an impairment as noted in #1 above.
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AFFIRMATIVE ACTION OFFICE (Lake Superior State University)

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Completed 22 August 2020

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