Fillable Voluntary Self-Identification Form printable pdf download

Voluntary Self-Identification Form

We are subject to certain governmental recordkeeping and reporting reqUirements for the administration of civil

rights laws and regulations. In order to comply with these laws, we invite our employees to voluntarily selF-identify

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

any adverse treatment. The information will be I<ept confidential and will 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 a specific individual.

Employee Nf.lme _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Employee Number ____ _

Employee Signature _ _ _

Date

_ _ _ 1------_1----_-

understand the reason for this request for voluntary self-identification as stated above and choose to

decline.

I understand the reason for this request for voluntary self-identification as stated above and have opted to

complete this form.

GenderO Male

Female

Race/Ethnicity

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

culture or origin, regardless of race.

DYes

If you answered no to the question above, please select the appropriate designation below:

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 original 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, KoreCl,

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 or South America (including Central America), and who maintain tribal affiliations or

community attachment.

Two or More Races (Not Hispanic or Latino) - All persons Who identify with more Ulan one of the above

five races.

If you have any questions regarding this form, please contact your Human Resource department or your

supervisor.

<92008 Payc/lex. Inc.

1/08

Voluntary Self-Identification Form