Eeo-1 Voluntary Self Identification Form printable pdf download

EEO: EEO-1 Voluntary Self Identification Form

The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees

must invite applicants to self-identify gender, and race and complete an EEO-1 report each year. Completion of

this data is voluntary and will not affect your opportunity for employment or terms or conditions of

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 Human Resources Department. Please return completed forms to the Payroll

Department.

Name: __________________________________

Job Title: ________________________________

GENDER:

(Please check one of the options below)

_____ Male

_____Female

RACE/ETHNICITY:

(Please check one of the descriptions below corresponding to the ethnic group 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 Other 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.

___ American Indian 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 maintain tribal affiliation or

community attachment.

___ Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above

five races.

Date completed: ___________________________

PLEASE RETURN FORM TO PAYROLL DEPARTMENT. Thank you for your participation.

Eeo-1 Voluntary Self Identification Form