Marshall University EEO/AA Self-Identification Form

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Marshall University
EEO/AA Self-Identification Form

In accordance with the U.S. Department of Education policies for affirmative action employers, universities and colleges receiving federal funds are required to collect data regarding applications for positions on the campus. This information is used to monitor the success of our recruitment efforts. Your participation is voluntary and refusal to participate will not subject you to adverse treatment in the hiring process. No personally identifiable information provided on the form will be shared with the department or the recruitment committee without your specific written permission.

Position Title:

Department:

Line #:

1. Ethnicity: (The following categories have been developed by the federal government in order to provide for the collection and use of compatible, non-duplicated racial and ethnic data by federal agencies).

Hispanic or Latino

Not Hispanic or Latino

2. Race: (The following categories have been developed by the federal government in order to provide for the collection and use of compatible, non-duplicated racial data by federal agencies).

1. American Indian or Alaskan Native	5. Native Hawaiian or Other Pacific Islander
2. Asian	6. White
3. Black or African American
4. Hispanic or Latino

3. Gender:

Female

Male

4. Veteran:

Yes (If Yes, please check one)	No
Disabled Veteran Vietnam Veteran Disabled Vietnam Veteran

5. Disabled:

Yes	No
(If Yes, please check designations that apply)
Acoustically Impaired Legally Blind Learning Disabled Mobility Impaired Multiply Impaired Other Impairment Visually Impaired (not blind)

6. Citizenship:

USA	Other Country (specify)

7. Where did you learn of this position?

America's Job Exchange	Herald Dispatch	Personal Contact	Other:
Chronicle of Higher Education	HigherEdJobs.com	West Virginia Division of Rehabilitative Services
Diverse Issues	Hispanic Outlook	VA Vocational Rehabilitative Services

(OPTIONAL) I give permission for personally identifiable information from this form to be shared with the recruitment/search committee and/or the hiring unit.

Name/E-Signature: Date:

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