EEO/AFFIRMATIVE ACTION DATA
Heritage University is an equal opportunity/affirmative action employer, and considers all employment decisions without regard to race,
color, religion, gender, national origin, citizenship, age, mental or physical disabilities, veteran status, or any other prohibited basis. In
keeping with this philosophy and in an effort to comply with federal and state standards for equal opportunity employment, we ask that
you provide the information requested below.
Please note that the information provided is retained separately from your personnel file. Your cooperation is appreciated.
EMPLOYEE INFORMATION
Print Name: ___________________________________________________________
Date _______________________
Please Check One:
Male
Female
Please check as applicable
1 ‐ White
5 ‐ American Indian or Alaska Native
(not Hispanic or Latino)
(not Hispanic
2 ‐ Black or African American
or Latino)
(not Hispanic or
6 ‐ Native Hawaiian or other Pacific Islander
(not
Latino)
3 ‐ Hispanic or Latino
Hispanic or Latino)
4 ‐ Asian
7 ‐ Two or More Races
(not Hispanic or Latino)
(not Hispanic or Latino)
Please check ALL that apply
INVITATION TO SELF‐IDENTIFY VETERAN STATUS OR DISABILITY
As a government contractor, Heritage University. is subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 and
Section 503 of the Rehabilitation Act of 1973, as amended, which require government contractors to take affirmative action to employ
and advance in employment qualified special disabled veterans, veterans of the Vietnam era, and qualified individuals with disabilities. If
you are a veteran or are disabled, we would like to include you in our affirmative action program. A request to benefit under Heritage
University affirmative action program may be made now or at any time in the future.
The information you submit will be kept confidential, except that, if you are disabled, (i) supervisors and managers may be informed
regarding restrictions on the work or duties of disabled individuals and special 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 OFCCP, or the Americans
with Disabilities Act, may be informed.
This information is being requested will not subject you to any adverse treatment. Further, the information will not be used in a manner
inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 and Section 503 of the Rehabilitation Act of 1973, as
amended.
Not applicable
Special Disabled Veteran
, defined as (1) a veteran 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 Department of Veterans Affairs for a disability (i) rated at
30 percent or more, or (ii) rated at 10 or 20 percent if it has been determined that the individual has a serious employment disability
under 38 U.S.C. 3106; or (2) a veteran who was discharged and released from active duty because of a service‐connected disability.
Vietnam‐Era Veteran
, defined as a person who (1) served in the military, ground, naval or air service of the United States on active
duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any
part of such active duty occurred: (i) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (ii) between August
5, 1964 and May 7, 1975, in all other cases.
Other Protected Veteran
, defined as a veteran who served in the military, ground, naval or air service of the United States on
active duty during a war or in a campaign or expedition for which a campaign badge has been authorized, other than Special
Disabled Veterans or Vietnam‐Era Veterans.
Recently Separated Veteran
, defined as any veteran who served on active duty in the U.S. military, ground, naval, or air service
during the one year period beginning on the date of such veteran’s discharge or release from active duty.
Disabled individual
, defined as a person with a physical or mental impairment that substantially limits one or more major life
activities, has a record of such impairment, or is regarded as having such an impairment.
_________________________________________
____________________________________
Employee Signature
Date
THANK YOU FOR YOUR INFORMATION
This form will be maintained in a separate confidential file.