VOLUNTARY SELF-IDENTIFICATION FORM FOR EMPLOYEES
The CSU is an equal employment opportunity employer and is committed to treating all employees without regard to race, color, religion,
national origin, ancestry, physical or mental disability, medical condition, genetic information, marital status, sex (including gender
identity), age (over 40), sexual orientation, covered veteran status, or any other protected status.
This form has been developed to assist us in monitoring the diversity of our workforce, and in collecting data that is required for
compliance with State, Federal, and University reporting requirements. This form, and any data submitted on the form, will be kept
separate from your personnel file and will not be accessible by anyone involved with making recommendations or decisions regarding
your employment. While your reply will be most helpful to us in reporting accurate data, completing this form is entirely voluntary.
Employee Name (Last, First, Middle Initial) Date
Employee ID
Question 1. Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.)
Yes No
Question 2.
Regardless of your answer to Question 1, you may select one or more of the following categories that apply to you:
CATEGORY DEFINITION OF CATEGORY
American Indian or Alaska Native
Asian
Asian Indian
Cambodian
Chinese
Filipino
Japanese
Korean
Laotian
Vietnamese
Other Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Guamanian
Hawaiian
Samoan
Other Native Hawaiian or
Other Pacific Islander
White
A person having origins in any of the original peoples of North and South
America (including Central America) who maintains cultural identification
through tribal affiliation or community attachment.
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.
A person having origins in any of the black racial groups of Africa.
A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Revised 5-13-2010
