Self Identification Form Race/ethnicity, Gender, & Disability
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1O
AO 78A (11/06)
C
SELF IDENTIFICATION FORM
RACE/ETHNICITY, GENDER, & DISABILITY
Instructions - Part C
(Please read the instructions and Privacy Statement before completing form.)
1. Name (Last, First, MI)
2. Position
3. Social Security Number
Privacy Statement
You are requested to furnish this information to aid the federal judiciary in reporting on equal employment opportunities. Solicitation of this information is in
accordance with Judicial Conference of the United States policy. This information will be used in planning and monitoring fair employment practices programs. Your
furnishing this information is voluntary. Your failure to do so will have no effect on you or on your federal employment.
Specific Instructions: Please identify your gender and whether or not you have a disability. The categories below are designed to identify your basic racial and
national origin category. If you are of mixed racial and/or national origin, identify yourself by the category with which you most closely identify yourself. Place an X
in the box next to the appropriate category.
Name of Category
Description of Category
’
’
Gender:
F
M
F = Female M = Male Place an X in one or the other.
’
’
Disability:
N (5)
Y (1)
N = No
Y = Yes Place an X in one or the other.
Race / Ethnicity:
Choose only ONE of the following categories.
’
A person having origins in any of the original peoples of Europe, North Africa, or the Middle
(1)
White / Caucasian
East. Also includes persons not included in other categories.
A person having origins in any of the black racial groups of Africa. Does not include
’
(2)
Black / African American
Hispanics.
A person having origins in Mexican, Puerto Rican, Cuban, Central or South American, or
(3)
’
Hispanic or Latino
other Spanish cultures or origins.
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
(4)
’
Asian
Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea,
American Indian or Alaskan Native
A person having origins in any of the original peoples of North America, and who maintains
(5)
’
(Native American)
cultural identification through community recognition or tribal affiliation.
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
(6)
’
Native Hawaiian or Pacific Islander
Pacific Islands.
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