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Alternative “Suggested Employee Questionnaire”

The U.S. Equal Employment Opportunity Commission
DISCUSSION DRAFT ONLY

Equal Employment Advisory Council
Alternative “Suggested Employee Questionnaire”
for Self-Identification of Race/Ethnicity

INSTRUCTIONS
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM

Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin.

This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the employer to invite employees 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 kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes.

If you choose not to self-identify your race/ethnicity at this time, the federal government requires this employer to determine this information by visual survey and/or other available information. All information will be reported in the same seven race/ethnicity categories identified below.

INVITATION TO SELF-IDENTIFY
PLEASE ANSWER THE FOLLOWING QUESTION

What is your race/ethnicity? You may mark only one box.

___ Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

___ White (not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (not Hispanic or Latino): a person having origins in any of the black racial groups of Africa.

___ Asian (not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

___ Native Hawaiian or Other Pacific Islander (not Hispanic or Latino): a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

___ American Indian or Alaska Native (not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

___ Two or More Races (not Hispanic or Latino)



DISCUSSION DRAFT ONLY

This page was last modified on October 29, 2003.