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.
This employer is a Government contract 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
retire pay, would be entitle 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.
VETERAN SELF-IDENTIFICATION FORM FOR EMPLOYEES
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
mm/dd/yyyy
Protected Veterans.
Definition
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 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.
Employee's Name (Last, First, Middle Initial) Employee ID
Revised 3/27/2014
