VOLUNTARY SELF-IDENTIFICATION FORM FOR EMPLOYMENT APPLICANTS

It is CSUF policy to provide equal employment opportunity and to advance in employment all qualified individuals without regard to race, color, religion, national origin, ancestry, physical or mental disability, medical condition, genetic information, marital status, sex, gender identity, gender expression, age (over 40), sexual orientation, or protected veteran status.

CSUF is interested in monitoring the effectiveness of our recuitment efforts and the diversity of our workforce. This information has been developed to assist us in these efforts and in collecting data that is required by University policies and state and federal laws, including Executive Order 11246, the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, and Section 503 of the Rehabilitation Act of 1973, as amended.

This form, and any data submitted on the form, will be kept separate from your personnel file and will not be accesible by anyone involved with making decisions regarding your employment. While your reply will be most helpful to us in reporting accurate data, completing this form is entirely voluntary; refusal to complete the form will not adversely affect your employment.

If you have any questions pertaining to this form or, due to a disability, require a reasonable accommodation to complete the form, please contact the division of Human Resources, Diversity and Inclusion at 657-278-3951.

 
 
 
 
 

Labor Certification Information

Compliance with this request is consistent with U.S. Department of Labor regulations mandated by laws and Executive Orders. The information is treated with confidentiality and used in summary form only. This data is not used in personnel decisions.

 
 
 

Question 1:

Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Question 2:

Regardless of your answer to Question 1, you may select one or more of the following categories that apply to you:  

Category
Definition of Category

A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.

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.

A person having origins in any of the black racial groups of Africa.

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

How did you learn about this vacancy?

 

Protected Veterans

Definitions

This employer is a U.S. 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:
  • A veteran of the U.S. military ground, naval or air service who is entitled to compensation (or who, but for the receipt of U.S. military retired pay, would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
  • 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 veterans' 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, paticipated 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 Service 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.

Self Identification

 

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.

 

           



Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.1 To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

 


9/20/2017
Your Name
Today's Date


Reasonable Accommodation Notice

Federal law requires employer to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

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1 Section 503 of the Rehabilitation Act of 1973, as amended. For mor information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labors' Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: Acording to the Paperwork Republication Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.