EEO-1 Voluntary Self-Identification Form
Area Agency on Aging of Western Arkansas 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, we invite employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.   The information will be kept confidential and will 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.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.



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Name and Address *
Enter name, address, city, state, zip on separate lines
Position Applied For *
Gender
Gender *
Ethnicity
Are you Hispanic or Latino? *
A person of Cuban, Mexican, Puerto Rican, Central or South  American, or other Spanish culture or origin, regardless of race.
Race
IMPORTANT - Only complete this section if you checked “No, I am not Hispanic or Latino” in the Ethnicity section above

What is your race?  Select ONE of the following categories:
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.
Native Hawaiian or Other Pacific Islander
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
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, and Vietnam.
American Indian or Alaska Native
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or more races
All persons who identify with more than one of the above five races.
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Electronic Signature
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