East Carolina University
Personnel Profile
Employee’s Name
__________________________________________________________
Social Security #
__________________________________________________________
Date of Birth
Handicap
__________________________________________________________
A handicap is any impairment, which substantially limits one or more major life activities.
A handicapped person is one who has such an impairment; has a record of such an impairment;
or is regarded as having such an impairment. The reporting of a handicap is voluntary.
_____ None or prefer not to report
_____ Blind or severely visually impaired
_____ Deaf or severely hearing impaired
_____ Loss or limited use of arms and/or hands
_____ Non-ambulatory (must use wheelchair)
_____ Other orthopedic impairment
(Including amputation, arthritis, back
injury, spinal bifida, cerebral palsy, etc.)
Race
_____ White
_____ Black
_____ Hispanic
Sex
_____ Male
Citizenship
_____ Non-resident Alien
_____ Permanent Resident
_____ Citizen
_____ Respiratory impairment
_____ Nervous system/Neurological disorder
_____ Mentally restored
_____ Mental retardation
_____ Learning disability
_____ Others (diabetes, heart disease, speech impediment)
_____ Other (please specify) _____________________
_____ Asian (including Pacific Islander)
_____ American Indian (including Alaskan Native)
_____ Female
Veteran Status
If you answer “NO” to question #1 (below), omit the next four questions.
If you answer “YES” to question #1 (below), answer all five questions
1. Are you a Veteran?
_________ Yes
__________ No
Veteran: a person who served in the Armed Forces of the United States on active duty, for reasons other than training, and has
been discharged under other than dishonorable conditions.
2. Did you serve during a period of war?
_________ Yes
__________ No
A “period of war” includes World War I (April 16, 1917 through November 11, 1918),
World War II (December 7, 1941 through December 31, 1946), Korean Conflict (June 27, 1950 through January 31, 1955),
the period of time between January 31, 1955 and the end of hostilities in Vietnam (May 7, 1975), the Persian Golf War
(1991), or the Iraq Conflict (2003).
3. Are you a Vietnam Era Veteran?
_________ Yes
__________ No
Veteran of the Vietnam Era: a person who served more than 180 days of active military service, any part of which was during
the period August 5, 1964 through May 7, 1975.
4.
Are you a Special Disabled Veteran?
_________ Yes
__________ No
Special Disabled Veteran: a veteran who is entitled to compensation under laws administered by the Veterans Administration
for a disability rated at 30 percent or more, or rated at 10 or 20 percent in the case of a veteran who has been determined to have
a serious employment handicap; or a person who was discharged from active duty because of service connected disability.
5.
Are you currently on active status with the National Guard? _________ Yes
__________ No
Active Status: eligible to be called for active duty in any of the branches of the military
(i.e. Army, Air Force, Marines, Navy, and National Guard).
10/07