Seasons Hospice Affirmative Action Form

Seasons Hospice Affirmative Action Form
Seasons Hospice is an equal opportunity employer and government contractor. It has been and shall continue to be both the agency official policy and the commitment of the agency to further equal employment opportunities in hiring or employment. Seasons Hospice is committed to the employment and advancement of minorities, females, individuals with disabilities and veterans. No question on the form is intended to secure information to be use for such discrimination. Completion of this form is voluntary and in no way affects your application for and/or employment. The agency is required by federal regulations to report information as requested below. The information provided will be held in the strictest confidence and will be maintained in a separate file.

Completing this form is voluntary, but we hope that you will choose to fill it 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. This information will be kept separate from your application.
Date of Application:

MonthDayYear
Date
Name

First NameLast Name
Position Applied For:
Gender:

MaleFemaleNon-BinaryI don't wish to answerOther
Race/Ethnic Group:

WHITE. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.BLACK or AFRICAN AMERICAN. A person having origins in any of the black racial groups of Africa.HISPANIC or LATINO. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.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.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, and Vietnam.NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.People who identify as more than one race.
Disability Status:

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 palsy

                • HIV/AIDS

                • Schizophrenia

                • Muscular dystrophy

                • Bipolar disorder

                • Major depression

                • Multiple sclerosis

                • Missing limbs or partially missing limbs

                • Post-traumatic stress disorder (PTSD)

                • Obsessive compulsive disorder

                • Impairments requiring the use of a wheelchair

                • Intellectual disability (previously called mental retardation)
Question:

Yes, I have a disabilityNo, I do not have a disabilityI don't wish to answer
Should be Empty:

Seasons Hospice Affirmative Action Form

Disability Status: