APPENDIX 22 INVITATION TO SELF-IDENTIFY

AA-1 Revised:  01/11/11
APPENDIX 22

KANSAS STATE UNIVERSITY
K-STATE RESEARCH AND EXTENSION
MANHATTAN, KANSAS

Federal and State laws and regulations require Kansas State University to invite applicants to voluntarily self identify.  Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment nor adversely affect your candidacy.  The information provided on this form will be used only in ways that are consistent with the Title VII, Vietnam Era Veterans’ Readjustment Assistance Act of 1974, the Americans with Disabilities Act Amendments Act, and Executive Order 11246.  It will not be included in your application or personnel file.  The information is considered confidential and will be used for the purpose of establishing protection under the law, determining appropriate accommodations, administering first aid, and compliance with laws and regulations.

Position Applied For:

Name:   

Date:

1.    Gender:        Male        Female


2.    Race/Ethnicity:

      White

      Black/African American

      Hispanic/Latino

      Native Hawaiian/Pacific Islander

      Asian

      American Indian/Alaskan Native

      I Choose Not to Self-Identify

3.    Disability

Individual with a disability means any person who: (a) has a physical or mental impairment which substantially limits one or more major life activities, such as, reading, walking or speaking; (b) has a record of such impairment; or (c) is regarded as having such an impairment.

Are you an individual with a disability?        Yes        No

Please indicate whether you will need accommodations during the interview process.        Yes        No       
If Yes, please describe:      

4.    Veteran Status

Are you a disabled veteran?        Yes        No

Are you a recently separated veteran (three years or less)?        Yes        No

Are you an Armed Forces Service Medal Veteran?        Yes        No

Are you a Vietnam Era Veteran (between August 5, 1964, and May 7, 1975)?        Yes        No
If Yes, date of discharge:   

5.    How did you first learn of the position?  (Please check any that apply.)

        Newspaper - hard copy

        Newspaper - website

        Radio

        College Advisor

        Email notification from Extension Operations

        K-State Research and Extension's jobs website

        University Employment Listings website

        Non-University Employment Listings website

        Other