Employee Equal Opportunity & Affirmative Action Survey

The University is required to keep a record of the ethnic background of its employees. You are requested to complete this form voluntarily. If you choose not to provide the information, your employer will make a "best guess" and forward it to the Human Resources Office.

Required fields are marked.

Submitter:

This form was filed by: Appointee Employer

Appointee Information:

Date:	(MM/DD/YYYY)
Name:
Email:
Department:
Position Number:
Position Title:

Sex:

Male Female

Race/Ethnicity:

Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.)

Yes No

Please select one or more racial categories to describe yourself:

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa (e.g., persons who identify as Portuguese, German, Lebanese, Arab, Egyptian).)

American Indian or Alaska Native (A person having origins in any of the original peoples of North, Central, and South America and who maintains trival affiliation or community attachment.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Native Hawaiian/Part Hawaiian or Other Pacific Islander:
Native Hawaiian or Part Hawaiian
Guamanian or Chamorro
Micronesian (not Guamanian or Chamorro)
Samoan
Tongan
Other (please specify):

Asian:
Chinese
Filipino
Japanese
Korean
Laotian
Thai
Vietnamese
South Asian and Asian Indian (A person having origins in any of the original peoples of the Indian subcontinent (e.g., India, Pakistan, Afghanistan, Bangladesh, Bhutan, Nepal, Sri Lanka).)
Other (please specify):