Employee Self Identification Form The following information is required for record keeping in compliance with Federal regulations. Your responses will help in developing and monitoring our Affirmative Action Plan and diversity initiatives. Information provided will be kept confidential except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans and disabled individuals, and regarding necessary accommodations, (2) safety and security personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (3) government officials investigating compliance will be informed. SEX Male Female ETHNICITY Please check one of the following categories to identify your ethnicity. Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin,regardless of race. Not Hispanic or Latino RACE Please check one or more of the following categories to identify your race. 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 people of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine 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: 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 peoples of Europe, the Middle East, or North Africa YOUR RESPONSE TO THE FOLLOWING INFORMATION REQUESTS IS VOLUNTARY VIETNAM-ERA VETERAN Are you a Veteran of the Vietnam-era? A Veteran of the Vietnam-era means a veteran, any part of whose active U.S. military, naval, or air service, was during the period August 5, 1964, through May 7, 1975, who (1) served on active duty for a period of more than 180 days and was discharged or released there from with other than a dishonorable discharge, or (2) was discharged or released from active duty because of a service-connected disability. No Yes SPECIAL DISABLED VETERAN Are you a Special Disabled Veteran? A Special Disabled Veteran means (1) a veteran 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 Veterans Administration for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 1506 of Title 38, U.S.C., to have a serious employment disability or (2) a person who was discharged or released from active duty because of a service-connected disability. No Yes PERSON WITH A DISABILITY Do you have any limitations due to your disability that may affect your ability to satisfactorily perform the position for which you have been hired? No Yes If yes, please explain______________________________________________________ Are there any reasonable accommodations which we could make to enable you to perform the job properly and safely? No Yes If yes, please explain______________________________________________________ EMPLOYEE SIGNATURE EMPLOYEE PRINT NAME Employee Self Identification Form 7-6-2010 DATE