Affirmative Action: Post-Offer Invitation to Self-Identify - Veteran, Gender & Race (VEVRAA & EO 11246)
[Note: This form can be used to collect veteran status, gender and race/ethnicity, which would apply to both the VEVRAA and Executive Order 11246, which requires affirmative action for women and minorities.]
[Company Name] is an equal opportunity employer. As a government contractor subject to Executive Order 11246 and the Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA), [Company Name] is required to submit reports to the U.S. Department of Labor and Equal Employment Opportunity Commission each year identifying the number of our employees belonging to each specified protected veteran category, gender and race/ethnicity category.
Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information provided will be kept confidential, maintained separate from other personnel records and only accessed by the human resource department.
Please return completed forms to the HR department.
Print Name: Print Job Title:
GENDER
- Male
- Female
RACE/ETHNICITY (check ONE box)
- Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
- 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 races.
PROTECTED VETERANS (choose ALL that apply)
- Active Duty Wartime or Campaign Badge Veteran - a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
- Armed Forces Service Medal Veteran - any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p. 159).
- Disabled Veteran - (1) a veteran of the U.S. military, ground, naval or air service 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 Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability.
- Recently Separated Veteran - a veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.
- I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
- I am NOT a protected veteran.
If you are a disabled veteran, it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.
The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of 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 the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
[The contractor should insert a brief provision summarizing the relevant portion of its affirmative action program here.]
Signature: Date:
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