Yes No
American Indian or Alaska Native
Asian
It is CSU policy to provide equal employment opportunity and to advance in employment all qualified individuals without regard to race, color,
religion, national origin, ancestry, physical or mental disability, medical condition, genetic information, marital status, sex, gender identity,
gender expression, age (over 40), sexual orientation, or protected veteran status.
The CSU is interested in monitoring the effectiveness of our recruitment efforts and the diversity of our workforce. This form has been developed
to assist us in these efforts and in collecting data that is required by University policies and State and Federal laws, including Executive Order
11246, the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, and Section 503 of the
Rehabilitation Act of 1973, as amended.
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; refusal to complete the form will not adversely affect your employment.
If you have a disability and need accommodation, please contact the Human Resources or Faculty Affairs Office to begin an interactive
discussion to identify and provide you a reasonable accommodation.
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.
CATEGORY DEFINITION OF CATEGORY
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.
Black or African American
Japanese
Native Hawaiian or Other Pacific Islander
White
Vietnamese
Laotian
Other Asian
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.
Guamanian
Samoan
Hawaiian
Other Native Hawaiian or
Other Pacific Islander
A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Ethnicity. 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.)
Race. Regardless of your answer to the above question, you may select one or more of the following categories that apply to
you:
VOLUNTARY SELF-IDENTIFICATION FORM FOR EMPLOYMENT APPLICANTS
Filipino
Korean
Chinese
Cambodian
Asian Indian
Gender. Please select one of the following:
Male Female
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box
below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach
and positive recruitment efforts we undertake pursuant to VEVRAA.
Definition
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the
Jobs for Veterans Act of 2002, 38 U. S. C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and
advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and
(4) Armed Forces service medal veterans. These classifications are defined as follows:
A “disabled veteran" is one of the following:
-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 Secretary of Veterans Affairs; or
-A person who was discharged or released from active duty because of a service connected disability.
A “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.
An “active duty wartime or campaign badge veteran” means a veteran 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 Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U. S. Military ground, naval, or air
service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive
Order 12985.
Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In
particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be
reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.
For more information, call the U. S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-
DOL.
VOLUNTARY SELF-IDENTIFICATION FORM FOR EMPLOYMENT APPLICANTS
Job/Position Number
Applicant's Name (Last, First, Middle Initial)
Self Identification
Disabled veteran
Recently separated veteran
Active wartime or campaign badge veteran
Armed forces service medal veteran
Date of discharge
I identify as one or more of the classifications of protected veteran listed
I am a protected veteran, but I choose not to self-identify the classification to which I belong
I am not a protected veteran
I am not a veteran
Protected Veterans.
mm/dd/yyyy
Revised 3/27/2014
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