EEO Self Identification

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Step 2 of 5 — IMS Employment Packet

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CONFIDENTIAL

Equal Employment Opportunity (EEO) Self-Identification Form

Completion of this form is voluntary. The information you provide will be kept confidential and will only be used in accordance with applicable laws and regulations.

Personal Information

Date *

Name *

First

Middle

Last

Position Applied For *

you Date Status

Gender Identification (Select one) *

Male
Female
Non-Binary
I do not wish to answer

Race / Ethnicity Identification (Select one) *

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)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
American Indian or Alaska Native (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)
I do not wish to answer

Veteran Status *

I am not a protected veteran
I identify as one or more of the classifications of a protected veteran
I do not wish to answer

Disability Status: Do you have a disability, or have you ever had one? *

Yes
No
I do not wish to answer

Definition of disability (according to the ADA): A physical or mental impairment that substantially limits one or more major life activities.

Confidentiality & Use

This information is collected for reporting and recordkeeping requirements and will not be used as part of the selection process. Submission is voluntary and refusal to provide it will not subject you to adverse treatment.

Date *

Signature *

Clear Signature

Packet ID

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