Voluntary Self-Identification Form – Community Medical Center

Voluntary Self-Identification Form

The following statistical information is used by community Medical Center only for compliance with federals laws. To comply with these laws, we invite you to voluntarily self-identify your race or ethnicity. Submission of this information obtained is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and separate from personnel files. It may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those requiring information to be summarized and reported to the federal government for civil rights enforcement.
Please check the EEO Identification Group that best applies to you:
- 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 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 maintain tribal affiliation or community attached.
- Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above races, excluding those who identify themselves as Hispanic or Latino.
Gender
- Male
- Female
Printed Name
Signature
Date