Fillable Self Id Form (California State University, Chico)

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Self Id Form (California State University, Chico)

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VOLUNTARY SELF-IDENTIFICATION FORM FOR
EMPLOYMENT APPLICANTS
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.
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.)
Yes
No
Race.
Regardless
of your
answer
to the
above question,
you
may select
one or more of the following
categories
that apply
to
you:
CATEGORY
DEFINITION OF CATEGORY
American Indian or Alaska
Native
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.
Asian
Asian
Indian
Cambodian
Chinese
Filipino
Japanese
Korean
Laotian
Vietnamese
Other
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,
and
Vietnam.
Black or African
American
A person having origins
in
any
of the
black racial groups
of Africa.
Native Hawaiian or Other Pacific
Islander
Guamanian
Hawaiian
Samoan
Other Native Hawaiian
or
Other Pacific
Islander
A person having origins
in
any
of the
original peoples
of
Hawaii, Guam, Samoa,
or other
Pacific
Islands.
White
A person having origins
in
any
of the
original peoples
of
Europe,
the Middle
East,
or
North
Africa.
Gender.
Please select one
of the following:
Male Female
VOLUNTARY SELF-IDENTIFICATION FORM FOR EMPLOYMENT
APPLICANTS
Protected
Veterans.
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.
Self
Identification
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
Disabled
veteran
Recently separated
veteran
Date
of discharge
mm/dd/yyyy
Active wartime
or
campaign badge
veteran
Armed forces service medal
veteran
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
Applicant's
Name
(Last, First, Middle
Initial)
Job/Position
Number
Revised
Voluntary Self-Identification of Disability Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 2
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities
1
. 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 include, but are not limited to:
Blindness
Bipolar disorder
Post-traumatic stress disorder (PTSD)
Deafness
Major depression
Obsessive compulsive disorder
Cancer
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Missing limbs or
Intellectual disability (previously called mental
Epilepsy
partially missing limbs
retardation)
Please check one of the boxes below:
☐ YES, I HAVE A DISABILITY (or previously had a disability)
☐ NO, I DON’T HAVE A DISABILITY
☐ I DON’T WISH TO ANSWER
___________________________________ ___________________________________
Your Name Today’s Date
Voluntary Self-Identification of Disability Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
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.
1
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
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.
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Self Id Form (California State University, Chico)

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Completed 23 July 2020

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