Questionnaire for Self-Identification of Race/Ethnicity "*" indicates required fields Equal Employment Advisory Council Revised Alternative suggested Employee Questionnaire for Self-Identification of Race/Ethnicity INSTRUCTIONS: PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin. Behavior Invention Services is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their race/ethnicity. 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 federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes. If you choose not to self-identify your race/ethnicity at this time, the federal government requires this employer to determine this information by visual survey and/or other available information. For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven categories identified below. The definitions for each category have been established by the federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below. INVITATION TO SELF-IDENTIFY: What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify. Hispanic or Latino: a person of Cuban, Mexican, Chicano, PuertoRican, South or Central American, or other Spanish culture or origin, regardless of race. White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American: a person having origins in any of the black racial groups of Africa. Asian: a person having origins in any of the original peoples ofthe Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity categories. Name* First Last Email* Signature*HiddenDate* MM slash DD slash YYYY
