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Applicant Self-Identification Form
Applicants are considered for all positions without regard to race, color, sex, national origin, veteran status, or disability status. As an Affirmative Action/Equal Opportunity employer, First Atlantic Health Care complies with government regulations and affirmative action responsibilities.
Please complete the Applicant Self-Identification Form to assist us with government record keeping, reporting, and other legal requirements. The data is for analysis and affirmative action purposes. Submission of 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 information below is voluntary. Thank you for your cooperation.
Name
Last First Middle
Position(s) Applied For:
Gender: X Male X Female
Race/Ethnic Group (Please check all that apply):
X Hispanic or Latino A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture or origin , regardless of race.
X American Indian or Alaskan Native: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.
X Asian: 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, & Vietnam.
X Black or African American: A person having origins in any of the black racial groups of Africa.
X Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
X White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
X Two or More Races: A person who primarily identifies with two or more of the above race/ethnicity categories.
X I prefer not to answer.
____________________________________________ _______________
Signature Date
If you should have any questions regarding this form, please contact Human Resources.
Applicant Self-Identification Form
Name:
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:
• A “disabled veteran” is one of the following:
o 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
o a person who was discharged or released from active duty because of a service-connected disability.
• A “recently separated veteran” means any 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.
• An “active duty wartime or campaign badge veteran” means 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.
• An “Armed forces service medal veteran” means a 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.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
X I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
X I AM NOT A PROTECTED VETERAN
X I PREFER NOT TO ANSWER
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be maintained confidentially and used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.