Employee Self-Identification Form

Emp ID:

Name

First NameLast Name

Date

Tri-County Electric Membership Corporation is a Federal contractor and an Equal Opportunity Employer. Tri-County Electric Membership Corporation is collecting demographic data from applicants and employees to ensure nondiscrimination in all aspects of employment as well as for federal and/or state reporting purposes. In addition, we are subject to 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 protected veterans. In order to comply with these laws, Tri-County Electric Membership Corporation, invites applicants and employees to voluntarily self-identify their gender, race/ethnicity and protected veteran status. Tri-County Electric Membership Corporation does not discriminate on the basis of race, religion, color, sex, sexual orientation, gender identity, pregnancy, age, protected veteran status, non-disqualifying physical or mental disability, national origin, genetic information, or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may 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.

Name*

First NameLast Name

Date

MaleFemaleI choose not to identify

Hispanic or LatinoWhite (not Hispanic or Latino)Black or African American (not Hispanic or Latino)Native Hawaiian or Pacific Islander (not Hispanic or Latino)Asian (not Hispanic or Latino)American Indian/Alaska Native (not Hispanic or Latino)Two or More Races (not Hispanic or Latino)I Choose not to Self-Identify

I identify as one or more of the classifications of protected veterans as defined on the following pageI am not a protected veteranI Choose not to Self-Identify

Personal and Confidential
This page contains sensitive information, store in secure "Affirmative Action Forms" files, separately from personnel records.

Ethnicity and Race Definitions

· Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

· White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

· Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

· Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

· Asian (Not Hispanic or Latino) - 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 Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

· Two or More Races (Not Hispanic or Latino) – A person who identifies with more than one of the above five races.

Protected Veteran Definitions

· Disabled Veteran - 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.

· Recently Separated Veteran - 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.

· Active-Duty Wartime or Campaign Badge Veteran - 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.

· Armed forces service medal veteran - 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.

I identify as one or more of the classifications of protected veteran listed aboveI am not a protected veteran

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 qualifed people with disabilities.* To help us measure how well we are doing, we are asking you to tell us if you have a disaiblity or if you ever had a disability. 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.

If you already work for us, your answer will not be used against you in any way. Because a person may become disbled at any time, we are required to ask all of 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	Autism	Bipolar Disorder
Deafness	Cerebral Palsy	Major Depression
Cancer	HIV/AIDS	Epilepsy
Diabetes	Schizophrenia	Muscular Dystrophy
Multiple Sclerosis (MS)	Missing limbs or partially missing limbs	Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder (PTSD)	Intellectual Disability (previously called mental retardation)	Impairments requiring the use of a wheelchair

Yes. I have a disability (or previously had a disability)No, I don't have a disabilityI don't wish to answer

Signature*

Date

Reasonable Accommodation Notice

Federal law requires employers 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.

Request for Reasonable Accommodation

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

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

Employee Self-Identification Form

Voluntary Self-Identification of Disability