Eastern Illinois University is required to compile summary data from applicants regarding characteristics related to equal employment opportunity. Although the return of this form is optional, you are encouraged to complete it and submit it electronically. Refusal to provide such information will not subject the applicant to any adverse treatment.

Position Applied For: Position Number:

Last Name: First Name: Middle Name/Initial:

Gender: Female Male

RACIAL / ETHNIC BACKGROUND: (Please select only one)

White, Non-Hispanic: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Black, Non-Hispanic: A person having origins on any of the black racial groups of Africa (except those of Hispanic origin).

Asian: A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent.

American Indian or Alaskan Native: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

Native Hawaiian or Other Pacific Islander: Refers to the people having origins of any of the original peoples of these islands.

Are you HISPANIC or LATINO? Yes No

DISABILITY

Federal regulation defined "disability: as including such conditions as speech, hearing, visual and orthopedic impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, diabetes, heart disease, mental retardation, emotional illness, dyslexia, and alcohol and drug addiction."

Would you like to report a disability? Yes No
Disability

VETERAN STATUS

Are you a disabled veteran? Yes No
Are you a Vietnam-era veteran? Yes No
Are you a veteran from any other era other than Vietnam? Yes No

HOW DID YOU LEARN OF THIS POSITION? (Select One)