Equal Employment Opportunity Voluntary Self-Identification Survey

Our organization is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law.  No question on this form is intended to secure information to be used for such discrimination.

Our organization is required by federal regulations to report information as requested below.  Your contribution of this information is completely voluntary.  The information you provide is strictly confidential and will be maintained separate from your personnel file.  You may inform us of your desire to benefit under the program at this time and/or any time in the future.

Please choose one race/ethnic group

Definitions

• Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
• White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
• Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
• Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
• Asian (Not Hispanic or Latino) – 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.
• American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
• Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.

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