Voluntary Self-Identification Survey Form
Affirmative Action Employer

Thank you for filling out the Employment Application Form. Please continue by filling out the following:

TO THE APPLICANTS: Our company is an Affirmative Action/Equal Employment Employer and as such, we are required to collect and maintain information related to applicants in order to meet governmental recordkeeping and reporting requirements and to monitor the effectiveness of our outreach, recruitment and other employment practices.

At this time, we are asking you to help us meet our obligations by providing the information listed on the following pages. Please note that the information will be used only in accordance with the provisions of applicable laws, executive orders, and regulations. Providing this information is voluntary and refusal to so will not result in any adverse treatment. The information you provide will be held in strict confidence except that:

  1. Necessary management and supervisory personnel may be informed to ensure proper placement and to provide reasonable job accommodations;
  2. First aid and safety personnel may be informed to the extent appropriate, if the condition might require emergency treatment; and
  3. Government officials investigating affirmative action program compliance may have access to reported information.

Thank you for your cooperation in this important initiative.

Congregational Home abides by the requirements of federal laws which prohibit discrimination of individuals with the following legally protected status: race, color, religion, sex, sexual orientation, gender identity, national origin, disability and protected veterans. Congregational Home also abides by affirmative action requirements to employ and advance in employment qualified individuals without regard to race and sex (per Executive Order 11246), disability (per 41CFR 60-741.5(a),and protected veteran status (per 41CFR 60-300.5(a).

Our company is an Affirmative Action/Equal Employment Employer and as such, we are required to collect and maintain information related to applicants in order to meet governmental recordkeeping and reporting requirements and to monitor the effectiveness of our outreach, recruitment and other employment practices.

PART I. General Information

Name(Required)
MM slash DD slash YYYY

PART II. Referral Source

Please indicate how you heard about this opening(Required)

PART III. Gender, Ethnicity and Race Information

Gender
CHECK ONE
Ethnicity
CHECK ONE
Race
CHECK ONE: (do not respond if you selected Hispanic or Latino above)

PART IV. Protected Veterans

The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran.
Disabled Veteran 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 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.
Recently Separated Veteran 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.
Active Duty Wartime or Campaign Badge Veteran 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.
Armed Forces Service Medal Veteran 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.
Are you a Protected Veteran?
CHECK ONE
If you are a disabled veteran, you may use the space below to tell us about: 1) Any special skills, knowledge, or abilities which may qualify you for positions within Congregational Home so that you can be considered for positions of that kind, and 2) Any reasonable accommodation that you may need because of a disability which would enable you to engage in the application process or perform the essential functions of the job properly and safely. This might include, but is not limited to, a change to application or work procedures, documents in an alternate format, sign language interpreter, or specialized equipment.