ADP Employee Data

OMB Control No: 1250-0005
Expiration Date: 01/31/2017



Note: Completion of race and ethnicity information is voluntary and is not a requirement.

Ethnicity:

Hispanic or Latino
Not Hispanic or Latino

 I decline to identify my ethnicity.


Race:

If not Hispanic or Latino select one or more values

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or More Races

 I decline to identify my race.


Gender:   Male  Female

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. 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 Autism Bipolar disorder
Post-traumatic stress disorder (PTSD) Deafness Cerebral palsy
Major depression Obsessive compulsive disorder Cancer
HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair
Schizophrenia Missing limbs or partially missing limbs Intellectual disability (previously called mental retardation)
Epilepsy Muscular dystrophy Diabetes

Invitation to self-identify as an individual with a disability

Invitation to self-identify as an individual with a disability (Spanish)

I have read the above invitation to self-identify as an individual with a disability.

 YES, I HAVE A DISABILITY (or previously had a disability)

 NO, I DON'T HAVE A DISABILITY

 I DON'T WISH TO ANSWER

Protected Veteran Status


Why are we asking

If this employer is a federal contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act (VEVRAA) of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAAA), it is required 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.

How will this information be used?
If this employer is a government contractor subject to VEVRAA, this information will be used to measure the effectiveness of its outreach and positive recruitment efforts it undertakes pursuant to VEVRAA. This information is being requested on a voluntary basis and will be kept confidential as required by law. Refusal to provide the requested information will not subject you to any adverse treatment. If provided, this information will not be used in a manner inconsistent with VEVRAA.

What is a Protected Veteran

Disabled Veteran:

(a) A veteran of the U.S. military, ground, naval, or air service 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 discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran:

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.

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.

Armed Forces Service Medal Veterans:

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 the Executive Order 12985.

 I identify myself as one or more of the classifications of the protected veteran below:

Disabled Veteran

Recently Separated Veteran      Discharge Date:

Active Duty Wartime or Campaign Badge Veteran

Armed Forces Service Medal Veteran

  I am not a protected veteran.

  I decline to self-identify.