Prestige Self-Identification Form

    Self-Identification Form

    PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

    Prestige Companion and Homemakers, LLC. is requesting information about race and gender in order to comply with government reporting requirements and in order to ensure equal employment opportunity.

    Submission of this information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Federal Affirmative Action regulations.

    Employee Name (Last, First, & Middle)

    Position

    Date

    Male

    Female

    I choose not to self-identify

    White (Not Hispanic or Latino)

    Black or African American (Not Hispanic or Latino)

    Hispanic or Latino

    Asian (Not Hispanic or Latino

    American Indian/Alaska Native (Not Hispanic or Latino)

    Native Hawaiian Or Pacific Islander (Not Hispanic Or Latino)

    Two Or More Races (Not Hispanic Or Latino)

    I Choose Not To Self-Identify

    Government contractors are required to take affirmative action to employ and advance in employment veterans in the following classifications:

    • 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.

    • 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.

    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, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts.

    I identify as one or more of the classifications of protected veteran listed above

    I am not a protected veteran

    I decline to disclose my protected veteran status

    If you are disabled veteran, please let us know if there any reasonable accommodations we could make that would enable you to be considered for a job opening or perform the essential functions of the position you hold.

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