VOLUNTARY SELF IDENTIFICATION SURVEY

Eastridge Church is subject to certain governmental record-keeping and reporting requirements for the administration of civil rights laws and regulations. To comply with these laws, the employer invites employees to voluntarily self-identify ethnicity, race, gender, and veteran and disability status. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information is kept confidential and is only 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 any specific individual.

The information requested will be kept confidential and will not be filed with, or retained as a part of, your personnel file. While we would appreciate each employee completing a form, doing so is entirely optional.

Name:

LAST	FIRST	MIDDLE

Position you now hold: ___________________________________________________________

1. Are you Hispanic or Latino/a? A person of Cuban, Mexican, Chicano/a, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Yes (Skip to question #3) No (Go to question #2)	3. What is your gender?
Male Female
2. What race or races do you consider yourself to be? (Check all that apply)
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
Native Hawaiian or other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific Islands
Asian: 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
American Indian or Alaskan Native: a person having in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
I do not wish to Self-Identify

Vietnam Era Veterans
Are you a Vietnam Era Veteran, a person that served a minimum of 180 days active duty in the Armed forces between 8/5/64 and 5/7/75? YES NO
Other Protected Veterans
Are you a veteran, a person who has served on active duty during a war or in a campaign or expedition for which a campaign ribbon or badge has been authorized? YES NO
Special Disabled Veterans
Are you a special disabled American Veteran? A special disabled veteran is a person that is entitled to disability compensation under the laws administered by the Veterans Administration for disability rated at 30% or more, or rated at 10 to 20 percent in the case of a veteran who has been determined under section 1506 of Title 38 U.S.C. to have a serious employment disability; or a person whose discharge or release from active duty was for a disability incurred in the line of active duty. YES NO
Newly Separated Veterans
Are you a newly separated veteran, a person who has served on active duty in the US military, ground, naval or air service during the one-year period beginning on the date of your discharge or release from active duty?
YES NO
I do not wish to Self-Identify

Individual with a Disability
Are you an individual with a disability? An individual with a disability means any person who: (1) has a physical or mental impairment which substantially limits one or more of life's activities; (2) has a record of such an impairment; or (3) is regarded as having such an impairment. YES NO
I do not wish to Self-Identify

Please return completed forms to _________________________ by ______________________.

THANK YOU FOR YOUR ASSISTANCE. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.