Fillable Self ID IVCC (Illinois Valley Community College)

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Self ID IVCC (Illinois Valley Community College)

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U.S.A. forms for Illinois Valley Community College

BROWSE ILLINOIS VALLEY COMMUNITY COLLEGE FORMS

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Applicant Self-Identification Form
Applicants are considered for all positions without regard to race, color, sex, national origin, veteran status,
or disability status. As an Affirmative Action/Equal Opportunity employer, IVCC complies with government
regulations and affirmative action responsibilities.
Please complete the Applicant Self-Identification Form to assist us with government record keeping,
reporting, and other legal requirements. The data is for analysis and affirmative action purposes. Submission
of 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. Completion of information below is voluntary. Thank you for your cooperation.
Position Applied for:
Name:
Last First Middle
Email: Date:
Address: City:
State: Country (if other than US): Zip:
Gender: Male Female
Do you consider yourself to be Hispanic/Latino? I prefer not to answer.
Yes No
Hispanic or Latino: A person
of
Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin.
Race/Ethnic Group (Please check all that apply):
American Indian or Alaskan
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 commun
ity attachment.
Asian
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, & Vietnam.
Black or African American
A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific
Islander
A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
White or Caucasian
A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
I prefer not to answer.
Referral Source:
IVCC Website
Other
Advertisement Source:
School Career Center
Chronicle of Higher Education
State Employment Office
Applicant Self-Identification Form
Name:
IVCC, 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:
o 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
o 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.
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.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF
PROTECTED VETERAN LISTED
ABOVE
I AM NOT A PROTECTED VETERAN
I PREFER NOT TO ANSWER
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.
The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans'
Readjustment Assistance Act of 1974, as amended.
The information you submit will be kept confidential, except that (i) supervisors and managers may be informed
regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first
aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might
require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of
Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Because we do business wi
th the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
i
To help us measure how well we are doing, we are asking you to tell us if you
have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work
for us, your answer will not be used against you in any way. Because a person may become
disabled at any time, we are required to ask all of our employees to update their information every five years.
You may voluntarily self-identify as having a disability on this form without fear of any punishment because you
did not identify as having a disability earlier.
How do I know if I 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 includ
e, but are not limited to:
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Post-traumatic stress disorder (PTSD)
Obessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental
retardation)
Bipolar disorder
Major depression
Multiple sclerosis(MS)
Missing limbs or
partially missing limbs
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular
dystrophy
Please check one of the boxes below:
__________________________
Your Name
__________________
Today’s Date
YES, I have a disability (or previously had a disability)
NO, I Don't have a disability
I don't wish to answer
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
Federal law
requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of
reasonable accommodation include making a change to the application process or work procedures, providing
documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at
www.dol.gov/ofccp.
PUBLI
C 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.
PLEASE NOTE: The EMAIL button may not function in all web browsers. If you experience difficulty with
the email button, PLEASE SAVE OR PRINT IT and return to Human Resources.
Saved forms can be emailed to: Human_resources@ivcc.edu.
Printed forms can be mailed to: IVCC, Human Resources, 815 N. Orlando Smith Road, Oglesby, IL 61348.
Submit by Email to humanresources@ivcc.edu
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Self ID IVCC (Illinois Valley Community College)

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Completed 22 July 2020

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