Voluntary Self Identification FormInstructionsPlease read all instructions carefully before completing this form. WACOSA is committed to Equal Employment Opportunity (EEO) and Affirmative Action (AA) recordkeeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their race/ethnicity. Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department. If you choose not to self-identify your race/ethnicity at this time, the federal government requires WACOSA to determine this information by visual survey and/or other available information.Name First Middle Initial Last Position Applied For Date MM slash DD slash YYYY GenderPlease mark the one box that describes the gender with which you primarily identify. Male Female I do not wish to disclose Race/EthnicityPlease mark the one box that describes the race/ethnicity with which you identify. 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 Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples 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. Native American or Alaska Native (Not Hispanic or Latino): 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. How did you hear about this position?Please check one box. Referral Unemployment Agency/MinnesotaWorks.net Advertisement at School/Work Newspaper Advertisement Contacted by WACOSA Hiring Manager/HR Online Advertisement WACOSA Website Walk-In Please specify: Voluntary Self-Identification of DisabilityWhy are you being asked to complete this form?We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if 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: Autism Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS Blind or low vision Cancer Cardiovascular or heart disease Celiac disease Cerebral palsy Deaf or hard of hearing Depression or anxiety Diabetes Epilepsy Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome Intellectual disability Missing limbs or partially missing limbs Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Please check one of the boxes below: Yes, I have a disability, or have a history/record of having a disability. No, I don't have a disability, or a history/record of having a disability. I don't wish to answer. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete. OMB Control Number 1250-0005. Expires 05/31/2023.NameThis field is for validation purposes and should be left unchanged.