Applicant Voluntary Equal Employment Opportunity Self Identification Survey

Hi,

Thank you for applying for a job at MicroCare!

We look forward to reviewing your information to see if we might be a fit to work together.

MicroCare invites all applicants to take the attached survey which asks you to self-identify your gender, race/ethnicity, protected veteran and disability status.

This request is voluntary and confidential.

We use the information to complete reporting requirements that we comply with as a vendor to the federal government.

There is no penalty should you choose to not provide this information.

If we determine that your qualifications meet our requirements, someone from our office will be in touch to conduct an initial interview.

Thank you for your interest in MicroCare and best of luck to you in your job search!

Question Title

* 1. Please enter your name and job title below for data collecting purposes. As a reminder, this survey will remain confidential.

Name:

Position Applying For:

Today's Date:

Question Title

* 2. Please check the appropriate Gender Identification:

Male

Female

I prefer not to identify.

Question Title

* 3. If applicable, please select the appropriate veteran status.

Vietnam Era Veteran (Served between 8/5/1964-5/7/1975

Disabled Veteran (Receives 30% military disability)

Newly Separated Vet. (Released from active duty less than one year before today's date.)

Other Eligible Vet (Authorization Campaign badge)

I am not a Veteran

I prefer not to identify.

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* 4. Do 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:

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)

Yes, I have a disability (or previously had a disability)

No, I don't have a disability

I prefer not to identify.

Question Title

* 5. Please check the appropriate Race/Ethnicity designation:

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 original people of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino): A person having origins in any of the original people 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 American (including Central America), and who maintains tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.

I prefer not to identify.