eeo info collection form

First Name*

Last Name*

Email Address*

EEO-1 Questions

Ethnicity

Hispanic or Latino: a person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

Race

You may select one or more races.

American Indian or Alaska 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 community 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, and Vietnam.

Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Black or African American: a person having origins in any of the black racial groups of Africa.

White: a person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Veteran Status

Disabled Veteran: (A) A person 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 (B) A person who was discharged or released from active duty because of a service-connected disability.

Active Duty Wartime or Campaign Badge Veteran: A person who served on active duty in the U.S. military, ground, naval or air service in a war, campaign or expedition in which a campaign badge has been authorized under laws administered by the Department of Defense.

Armed Forces Service Medal Veteran: A person who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Recently Separated Veteran: A person who was discharged or released from active duty within the last three years.

Question: Ethnicity?*

Question: Race?*

Question: Gender?*

Question: Veteran Status?*

FormCC-305

Voluntary Self-Identification of Disability

FormCC-305
OMB Control Number 1250-0005
Expires 05/31/2023

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you 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:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy

Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability

Missing limbs or partially missing limbs
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Question: Disability?*

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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