Optional Survey

Barber National Institute Applicant Self-Identification Form

READ BEFORE COMPLETING FORM

As an employer and government contractor, we comply with government regulations, including but not limited to the Vietnam Era Veteran's Readjustment Assistance Act of 1974 (VEVRAA), the Jobs for Veterans Act of 2003, as amended where applicable, as well as all other applicable current local, state and federal Equal Employment Opportunity Statutes. Our affirmative action responsibilities include but are not limited to employing and advancing in employment qualified minorities, females, disabled individuals and veterans in protected classifications as identified below. As a federal contractor, the company is required to take affirmative action to employ and advance in employment protected veterans, minorities, females and the disabled pursuant to applicable legislation. You may provide this information at this time and/or at any time in the future. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with applicable current legislation. The information you submit will be kept confidential, except that (i) Supervisors and managers may be informed regarding restrictions on the work or duties of disabled individuals, and regarding necessary accommodations; (ii) First aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by OFCCP, or enforcing the Americans with Disabilities Act, may be informed.

Important Instructions: When filling out this form, do not press the key. Use the key to move from one response to the next. When you have finished completing the form, click the 'Submit' button at the bottom of this page.

Your Name:
Please check this box if you wish to participate in this survey: I Would Not Like To Participate I Would Like To Participate
Select one of the following: Male Female
Select one of the following (Ethnic Origin): American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian Pacific Islander
Hispanic or Latino
White
Two or More Races


Veteran Status (Check One) If you believe you belong to any of the categories of protected veterans listed on page 2, please indicate by checking the appropriate box below. As a government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
Select one of the following: I identify as one or more of the classifications of protected veteran listed below
I am not a protected veteran
VETERANS STATUS DEFINITIONS
We are a government contractor subject to the Vietnam Era Veteran's Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C.4212 (VEVRAA), which requires government contractors to take affirmative action to employ and advance in employment: (1) Disabled veterans; (2) Recently separated veterans; (3) Active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined below.

All following definitions apply to persons who served in the active military ground, naval, or air service of the United States, and who were discharged or released therefrom under conditions other than dishonorable.

Disabled Veteran: A "disabled veteran" is one of the following: (a) A 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 (b) A person who was discharged or released from active duty because of a service-connected disability. (See Reasonable Accommodation Section)

Recently Separated Veteran: Any veteran during the three-year period beginning on the date of such veterans discharge or release from active duty in the U.S. military, ground, naval, or air service.

Armed Forces Service Medal Veteran: Veterans who, 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 No. 12985 (62 FR 1209). For those with internet access, the information required to make this determination is available at http://www.opm.gov/veterans/html/vg,edal2.htm A copy of the list may also be obtained by calling (301) 306-6752 and requesting that a copy be mailed to you.

Active Duty Wartime or Campaign Badge Veteran: A veteran who 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.

Pre-JVA Veteran:

  • Special Disabled Veteran: Veterans who are 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 for a disability rated at thirty (30) percent or more, or rated at ten (10) or twenty (20) percent in the case of a veteran who has been determined, under section 3106 of Title 38 - Veterans Benefits, to have a serious employment handicap; or a person who was discharged or released from active duty because of service-connected disability. (See Reasonable Accommodation Section)
  • Vietnam Era Veteran: Eligible veterans whose active U.S. military, naval, or air service was during the Vietnam era.
  • Pre-JVA Recently Separated Veteran: A pre-JVA veteran during the one-year period beginning on the date of the pre-JVA veteran's discharge or release from active duty.
  • Other Protected Veteran: A person who served on active duty 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.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veteran Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

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Voluntary Self-Identification of Disability
Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)
Please check on of the following:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
Today's Date:
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