PullmanSchool District Form 5110F:6

VOLUNTARY, CONFIDENTIAL INFORMATION FOR AFFIRMATIVE ACTION PURPOSES

This information is requested for the purpose of assuring equal employment opportunity and to prevent discrimination. This information will be confidential and will not be filed with or made part of your application/ personnel file.

NAME: ______Date: ______

POSITION OR POSITION(s) APPLYING FOR: ______

SEX: FEMALE MALE

AGE: UNDER 40 40 AND OVER

ETHNIC GROUP: Check either Yes or NoHispanic/Latino YES NO

If your answer is yes or no to the Ethnic Group, please complete the following:

RACIAL CATEGORIES: Check all that apply

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America(including Central America), and who maintains a tribal affiliation or community attachment.

Asian– A person having origin in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent: including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black– A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander– A person having origins in any of the original peoples of Hawaii, Guam,Samoa, or other Pacific Islands.

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

DISABILITY:For the purposes of Affirmative Action, do you consider yourself to be a person of disability as defined by the Americans with Disabilities Act? (A person who “has a physical or mental impairment that substantially limits one or more major life activities, or has a record of such an impairment or is regarded as having such an impairment?”)

NO YESIf yes, please explain. ______

______

VETERAN:Are you a disabled American Veteran? NO YES

Are you a veteran of Vietnam or other military action? NO YES

The Pullman School District complies with all federal and state rules and regulations and does not discriminate on the basis of race, creed, religion, color, national origin, age, veterans or military status, sex, sexual orientation, gender expression or identity, disability, or the use of a trained dog guide or service animal and provides equal access to designated youth groups. The following employee has been designated to handle questions and complaints of alleged discrimination: Robert Maxwell, Assistant Superintendent, Pullman School District Administrative Offices, 240 SE Dexter Street, Pullman, WA 99163, 509.332.3144. Applicants with disabilities may request reasonable accommodations in the application process by contacting the Personnel Coordinator at (509) 332-3584.

7/18/2013