University of Hawai‘i at Hilo
Invitation to Self-Identify Disability or Veteran Status

The University of Hawai‘i Hilo is an affirmative action employer, committed to employing and advancing in employment qualified persons with disabilities and qualified protected veterans.  If you would like to be included in our affirmative action program*, please let us know by completing this survey now or at any time in the future.  Your response is voluntary; declining to respond will not subject you to any adverse treatment.  Information you provide will be kept confidential, except that (1) supervisors and appropriate administrators may be informed regarding reasonable accommodations or work restrictions of persons with disabilities; (2) first aid personnel may be informed, when appropriate, if the disability might require emergency treatment; and (3) certain information may be disclosed if required by a civil rights enforcement agency, regulation, or law.

If you are individual with a disability, please check below if applicable:

a person who has a physical or mental impairment that substantially limits one or more major life activities (e.g., walking, seeing, hearing, or learning). 

Please notify your supervisor, director, or dean/vice chancellor, as soon as possible, if you need special assistance in the event of an emergency or workplace accommodations that would enable you to perform the job properly and safely; e.g., special equipment or modifications to the work environment or to the manner in which the job is customarily performed.

If you are a veteran, please check all applicable categories:


Other protected veteran:  served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Armed Forces service medal veteran:  while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Disabled veteran:  (1) veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability.

If you have checked any of above the fill out, print, sign and send this form to:
UH EEO/AA Office; Trailer E; 200 W. Kawili Street; Hilo, HI 96720
Phone:  (808) 932-7641 (V/T)

Position Type:
I understand that my response is voluntary:

Signature Date

VETS-100 Form; revised 04/15