Civil Rights Federal Government

EEO SELF-IDENTIFICATION FORM

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 governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. To comply with these laws, MAS Medical Staffing invites employees to voluntarily self-identify their race/ethnicity and gender. If you do not self-identify your race/ethnicity or gender at this time, the federal government requires this information to be determined by the employer, in its best judgment, through employment records, a visual survey and/or other available information.

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 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. Where records are maintained, they will be kept separately from the employee’s basic personnel file.

Invitation to Self-Identify

Name (Last, First, & Middle)

Position Title

Work Location

Date

What is your legal sex? Male Female

What is your race or ethnicity (as defined by the EEOC). You may mark only one box.

Hispanic or Latino: a person of Cuban, Mexican, 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.

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.

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.

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): all persons who identify with more than one of the above racial identities.

I do not wish to disclose.

Employee’s Name: Date:

Contact this candidate