Affirmative Action Data Request Form

ATTACHMENT E
Affirmative Action Data Request Form
123 I.G. Greer Hall
ASU Box 32053
Appalachian State University
Office of Equity, Diversity and Compliance
Boone, North Carolina 28608
Phone: 828-262-2144
Fax: 828-262-6646
Email: edc@appstate.edu

Thank you for your interest in a position opening at Appalachian State University. We would appreciate your assistance by providing the information requested on this form. The university is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the university invites applicants to voluntarily self-identify their race, ethnicity, sex, veteran status and disability status. 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 laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Although completion of this form is voluntary, the information you provide is vital to the university's compliance with applicable AA/EEO laws and university policies. The information also assists the university with its ongoing efforts and commitment to providing equal employment opportunities and increasing diversity in the workplace. This document and the information provided will be maintained separate and apart from your application. Thank you for your cooperation.

Last, First MI
Position Applied For
How did you find out about this position opening?
Are you Hispanic or Latino – a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race?
Please select one or more of the five race categories listed above. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African-American: A person having origins in any of the black racial groups of Africa. Asian: 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 or Vietnam. American Indian or Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America), who maintains tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Please select one.

Appalachian State University is a Government contractor 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.

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.

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.