Voluntary Self-Identification Form

We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite our employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will 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 a specific individual.

Employee ID
Date
Choose one
Gender
Race/Ethnicity
Hispanic or Latino -A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
If you answered no to the question above, please select the appropriate designation below:
Choose one
If you have any questions regarding this form, please contact your Human Resource department or your supervisor.
Form Status: Next

Draw Signature

Date 2023-03-11

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