Voluntary Self-Identification of Veterans
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;
ctive duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications
are defined as follows:
A “d
isabled 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 “re
cently 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.
tected veterans may have additional rights under USERRAthe 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.
As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of
Labor each year identifying the number of our employees belonging to each specifiedprotected veteran” category. If
you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the
appropriate box below. If you are not a veteran, select box 1 OR select the box(s) that apply to your veteran status.
I am
not a veteran. (I did not serve in the military.)
I belong to the following classifications of protected veterans (Choose all that apply):
I am NOT a protected veteran. (I served in the military but do not fall into any veteran categories listed above.)
I choose not to identify my veteran status.
____________________________________________ __________________________________
Name / W#
Today’s Date
Voluntary Self-Identification of Veterans
If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that
would enable you to perform the essential functions of the job, including special equipment, changes in the physical
layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other
accommodations. This information will assist us in making reasonable accommodations for your disability.
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.
Reasonable Accommodation Notice