Voluntary Self-Identification Form This employer is subject to governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, this employer invites employees to voluntarily self-identify their race, ethnicity, and gender. 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. COMPLETION OF THIS FORM IS VOLUNTARY AND IN NO WAY AFFECTS YOUR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND WILL BE MAINTAINED SEPARATELY FROM YOUR PERSONNEL FILE.Name(Required) First Middle Last Email(Required) Position(Required)Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Race White—Not of Hispanic Origin. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American—Not of Hispanic Origin. A person having origins in any of the Black racial groups of Africa. Asian—Not of Hispanic Origin. 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 Alaskan Native—Not of Hispanic Origin. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander—Not of Hispanic Origin. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or More Races—Not of Hispanic Origin. All persons who identify with more than one of the above five races. I elect not to identify Sex Male Female
