Voluntary applicant data sheet form for student employees Northern Arizona University is subject to certain nondiscrimination and affirmative action record keeping and reporting requirements which require the employer to invite applicants to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be treated in a confidential manner, and will be used to assist in fulfilling the university’s federal and state statistical reporting and affirmative action monitoring requirements. For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven categories identified below. The definitions for each category have been established by the federal government. Thank you very much for your consideration and assistance.Position applying for * Required Department * Required Date * Required MM slash DD slash YYYY Name as it appears on application * Required First Last Job Vacancy Number (appears at top of job description) Email * Required Contact phone * RequiredMailing address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about this job? * Required Word of mouth Internet search Job posting Advertisement (please name the publication or newspaper below): Other (please list below): Name of Publication * Required Other (more detail) * Required Invitation to Self-Identify If you need reasonable accommodation to participate in the hiring process, please contact the Disability Resources office at (928) 523-8773 or DR@nau.edu.Gender * Required Male Female I choose not to self-identify Race/Ethnicity Please review and respond to both questions. The categories listed below are the only options currently available for federal reporting purposes.Do you consider yourself to be Hispanic/Latino? (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race). * Required Yes No In addition to responding to the question above, select one or more of the following racial categories to describe yourself: American Indian or Alaskan Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community identification. Black or African American (not of Hispanic origin) - A person having origins in any of the Black racial groups of Africa. Asian - A person having origins in any of the peoples of the Far East, Southeast Asia, the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White (not of Hispanic origin) - A person having origins in any of the original people of Europe, Northern Africa, or the Middle East. choose to not self-identify Veteran Status Northern Arizona University is also subject to the Vietnam Era Veterans' 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 as follows: A “disabled veteran” is one of the following: 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 a person who was discharged or released from active duty because of a service-connected disability. A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An “active duty wartime or campaign badge veteran” means 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. An “Armed forces service medal veteran” means a veteran 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 12985. If you believe you belong to any of the categories of protected veterans listed above, 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.Veteran status identification * Required I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN 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 Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL. Northern Arizona University bases decisions on employment solely upon the individual’s qualifications for the position being filled. NAU recruits, hires and promotes for all job classifications without regard to race, sex, color, religion, age, national origin, disability, veteran status, sexual orientation, or gender identity. Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 05/31/2023 Page 1 of 2 Why are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. 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: •Autism•Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS•Blind or low vision•Cancer•Cardiovascular or heart disease•Celiac disease•Cerebral palsy•Deaf or hard of hearing•Depression or anxiety •Diabetes•Epilepsy•Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome•Intellectual disability•Missing limbs or partially missing limbs•Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)•Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depressionPlease check one of the boxes below: * Required YES, I HAVE A DISABILITY NO, I DON'T HAVE A DISABILITY I DON'T WISH TO ANSWER PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to the collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete Reasonable Accommodation Notice Federal law requires employers to provide a reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Completion of this form is not a request for accommodation. If you would like to request an accommodation, please contact the Disability Resources office at 928-523-8773 or email DR@nau.edu.