• Equal Employment Opportunity (EEO-1) Employee Self-Identification Form

  • The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Your employer invites you to self-identify gender and race/ ethnicity. Completion of this data is VOLUNTARY and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources.

  • PLEASE ANSWER THE FOLLOWING QUESTIONS:

  • What is your Gender?*
  • What is your race/ethnicity? Please mark the box that describes the race/ethnicity category with which youprimarily identify.*

  • Thank you for your participation.

  • Date*
     / /

  • Refusal to complete this form will not subject you to any adverse treatment. This form will be used for governmental reporting purposes only. If we have not received your completed form, the Company will interpret that to mean you have declined self-identification and will be required to obtain the necessary information from visual identification and/ or other available information.

  • Voluntary Self-Identification of Veterans

    Self-Identification

  •  As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. If you are not a veteran, select box 1 OR select the box(s) that apply to your veteran status.

     

  • *

  • (Choose all that apply)

  • Military Discharge Date (MM/DD/YYYY):
     - -
  • Today's Date*
     - -

  • Voluntary Self-Identification of Disability

  • Form CC-305
    Page 1 of 1                               OMB Control Number 1250-0005     Expires 05/31/2023

  • Date*
     / /

  • Why are you being asked to complete this form?

    We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

    Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs . (OFCCP) website at www.dol.gov/ofccp

    How do you know if you 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:

    • Autism
    • Autoimmune disorder, for example,
    • Depression or anxiety lupus, fibromyalgia, rheumatoid
    • Diabetes arthritis, or HIV/AIDS
    • Epilepsy
    • Blind or low vision
    • Cancer
    • Cardiovascular or heart diseaseirritable bowel syndrome
    • Celiac disease
    • Intellectual disability
    • Cerebral palsy
    • Gastrointestinal disorders, for example, Crohn's Disease, or
    • Missing limbs or partially missing limbs
    • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
    • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
  • Please check one of the boxes below:*

  • PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction 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.

  • For Employer Use Only

  • Employers may modify this section of the form as needed for recordkeeping purposes.

     

    For Example:

    Job Title:__________________                        Date Of Hire:__________________ 

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  • Should be Empty: