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Affirmative Action Survey - Applicant Data Record

Applicants are considered for all positions, and employees are treated during employment without regard to race, creed, color, religion, sex sexual orientation, national origin, age, disability, marital or veteran status, or being a member of the Reserves or National Guard.

As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246.

Solely to help us comply with government record keeping, reporting and other legal obligations as required under these and other laws and regulations, we ask that you please fill out this Applicant Data Record. This data is for analysis and affirmative action only. Submission of this information is voluntary. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

  Date / / (mm/dd/yyyy)
  Position Applied For
  Referral Sources
  First Name
  Middle Initial
  Last Name
  Phone() -
  Address
  City
  State
  Zip

Affirmative Action Survey - Gender

  If you wish to be identified, please check here and complete the survey:

 

  Select one:

Affirmative Action Survey - Ethnicity/Race

Ethnicity:

  Are you Hispanic or Latino?

Race - IMPORTANT - Only complete this section if you checked "No, I am not Hispanic or Latino" in the Ethnicity section above.

What is your race?

  Select ONE of the following categories:





Affirmative Action Survey - Veteran

We are a Government contractor 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 retired pay would be entitled 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.

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.

  Select one:

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. This information will assist us in making reasonable 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.

It is our policy to provide equal employment and advancement opportunities to all qualified individuals in all aspects of employment including but not limited to hiring, training, promotion, compensation, and all other personnel actions without regard to Disabled Veterans, Recently Separated Veterans, Active Wartime or Campaign Badge Veterans, or Armed Forces Service Medal Veterans or any other status that is protected by law. To achieve this goal, we are dedicated to taking affirmative action on behalf of Disabled Veterans, Recently Separated Veterans, Active Wartime or Campaign Badge Veterans, or Armed Forces Service Medal Veterans in compliance with Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). Employees and applicants are protected from coercion, intimidation, interference or discrimination for:

  1. filing a complaint;
  2. assisting or participating in an investigation, compliance review, hearing or any other activity related to the administration of Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), or any other Federal, state or local law requiring equal opportunity for disabled persons, special disabled veterans or veterans of the Vietnam era;
  3. opposing any act or practice made unlawful by Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA) or its implementing regulations;
  4. exercising any other right protected by Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA) or its implementing regulations.

Pursuant to this policy, a written affirmative action compliance program has been established which includes internal auditing and reporting systems to measure and evaluate the plans' effectiveness. This program is available for review upon request by any applicant or employee during regular business hours.

If you are an employee and a Disabled Veteran, Recently Separated Veteran, Active Wartime or Campaign Badge Veteran, or Armed Forces Service Medal Veteran that is covered by this program and would like to be considered under the affirmative action program, please tell us.

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities1. To help us measure how well we are doing, we are asking that you tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I 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 of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Impairments requiring use of a wheelchair
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Intellectual disability (previously called mental retardation)

  Select one:


Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter or using specialized equipment.


1 Section 503 of the Rehabilitation Act of 1973, as amended. for more information about this form or the equal employment obligations of Federal contractor, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp

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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