Equal Employment Opportunity (Eeo) Self-Identification Form printable pdf download

EQUAL EMPLOYMENT OPPORTUNITY (EEO)

SELF-IDENTIFICATON FORM

Pollywog Place is subject to certain governmental recordkeeping and reporting requirements for the administration of civil

rights laws and regulations. To comply with these laws, Pollywog Place invites employees to voluntarily self-identify their

race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse

treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of

applicable laws, executive orders, and regulations, including those that require the information to be summarized and

reported to the federal government for civil rights enforcement. When reported, data will not identify any specific

individual.

This form will be kept in a confidential file separate from your employment file.

Name (Last, First, MI): _______________________________________________________

Street Address: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Gender Identification (check one)

____ Female

____

Male

Race/Ethnic Identification (check one):

____

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish

culture or origin regardless of race.

If you did not check “Hispanic or Latino” above, please select one of the following race/ethnic identifications.

____

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.

_____ Decline self-identification

_________________________________________________

__________________

Applicant’s Signature

Date

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation,

veteran status, disability, or other protected characteristic.

Equal Employment Opportunity (Eeo) Self-Identification Form

Related Articles

Related forms

Related Categories