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 _ _ _
_ _ _ 1------_1----_-
understand the reason for this request for voluntary self-identification as stated above and choose to
I understand the reason for this request for voluntary self-identification as stated above and have opted to
complete this form.
Hispanic or Latino - A person of Cuban, Mexioan, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race.
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
Two or More Races (Not Hispanic or Latino) - All persons Who identify with more Ulan one of the above
If you have any questions regarding this form, please contact your Human Resource department or your
<92008 Payc/lex. Inc.