Form Eeo-1 - Self-Identification Form

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EEO-1 Self-Identification Form
Texas Biomedical Research Institute is subject to certain governmental recordkeeping and reporting requirements
for the administration of civil rights laws and regulations. In order to comply with these laws, Texas Biomed invites
applicants to voluntarily self-identify their gender, 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 kept 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 any specific individual.
This data is for periodic government reporting and will be kept in a Confidential File separate from the Application
for Employment.
Date: __________________________
Position(s) Applied For: ________________________________________________________________
Location of Position: __________________________________________________________________
 State Employment Agency  Friend
 Relative
Referral Source(s):
 Walk-In
 Company Website
 Other _________________________________________________________
Name: ______________________________________________
Phone _____-______-__________
Address: ____________________________________________________________________________
 Male
 Female
1. Gender
2. Ethnicity
Are you Hispanic or Latino?
A person of Cuban, Mexican, Puerto Rican, Central or South
American, or other Spanish culture or origin, regardless of race.
 Yes, I am Hispanic or Latino.
 No, I am not Hispanic or Latino.
3. Race
IMPORTANT – If you checked “No, I am not Hispanic or Latino” on #2, then check one or more of the following, as they apply:
 White
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
 Black or African American
A person having origins in any of the Black racial groups of Africa.
 American Indian/Alaskan Native
A person having origins in any of the original peoples of North America and South America (including
Central America), and who maintains tribal affiliation or community attachment.
 Asian
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
 Native Hawaiian or Other Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.


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