Affirmative Action Voluntary Survey

As part of our responsibilities as an employer with an Affirmative Action program and to comply with
government requirements regarding reporting, we would like to ask your help. Would you be willing to
complete the Applicant Dat Record? This document asks various questions to help us comply with
government record keeping, reporting and other legal requirements.

Completion of this form is voluntary. You will not be subject to any adverse personnel decision or action if
you do not provide the data. Your cooperation and completion of this form is greatly appreciated.

Government agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants.
This data is for analysis and affirmative action only.

Male Female
Check one of the following, Race/Ethnic group:
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native

Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals
with Physical or Mental Disability:
Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Adjustment Act of 1974 which
requires that they take affirmative action to employ and advance in employment qualified disabled veterans and
veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires
government contractors to take affirmative actions to employ and advance in employment qualified handicapped
individuals.

If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information.
The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to
perform the job to the best of your ability in a proper and safe manner. This information will be treated as
confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for
employment.
If you wish to be identified, please check:
Vietnam Veteran
Veteran of the U.S. military service?
Yes If yes, branch:
No
Years of military Service: Beginning Date: Ending Date:

If you believe you have a mental or physical disability that would substantially restrict or limit your ability to
perform the job or work you have applied for, or restrict or limit you in advancing in your employment, please
explain below:

Federal Law defines the term “qualified handicapped individual” as: “a person with a handicap who with
reasonable accommodation is capable of performing the essential functions of the particular job in education, skill
and experience. Please indicate your agreement with the information you have provided by completing the
following:
HR 017–I, Affirmative Action Survey
Rev. 09/01/06
Your name: E-mail address:

HR 017–I, Affirmative Action Survey

Rev. 09/01/06