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Self Identification Form

Voluntary and Confidential
Per the two Invitations to Self Identify referenced below in this form and the referenced laws and orders contained therein, Vibrint as a Government contractor is required to collect and retain the information on this form for reporting to the Federal government and for internal statistical analysis purposes.

In accordance with Section 503 of the Rehabilitation Act, Vibrint commits to making reasonable accommodations to the known physical or mental limitations of qualified individuals with disabilities and qualified disabled veterans, unless such accommodations would impose an undue hardship on the conduct of its business.

Again, providing this information is VOLUNTARY. As an applicant for employment, you are not required to provide this information and it is not a condition of employment nor will it affect consideration for employment. Information contained on this sheet is CONFIDENTIAL and will not be disclosed to any unnecessary party including those involved in hiring decisions.

Please read the two informational documents listed below and indicate you have read and understand them. At this point you will be able to answer the self-identification questions. If you choose not to answer these voluntary questions, check the box indicating I DECLINE then click on the "Submit" button below.
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Applicant Name

Name

Instructions

1. Please read the VOLUNTARY and CONFIDENTIAL Invitation to Self-Identify Gender, Ethnicity and Race and then check the box below to indicate you have read and understand the information.
2. Please read the VOLUNTARY and CONFIDENTIAL Invitation to Self-Identify to Protected Veterans and Qualified Individuals with Disabilities (Prior to offer) and then check the box below to indicate you have read and understand the information.

Decline Invitation

3. I DECLINE to self identify my gender, race/ethnicity, veteran status and disabilities. I understand that this will not affect consideration for employment as this information is confidential and is not provided to individuals involved in making hiring decisions. Please select I Decline, then click submit.

If you choose to answer, please continue by selecting the applicable box(es) in each of the sections below.

Race/Ethnic Designation

In this section, you will see questions regarding race and ethnic designation. This summarized information is reported to the Federal government for civil right enforcement and monitoring purposes. For these reporting purposes, if you mark “Yes, Hispanic or Latino”, your race will not be reported. The summarized information on race will be reported only for American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White or Two or More Races. If you select more than one race, you will be reported as Two or More races for purposes of the summarized information reported to the Federal government. Race/ethnic designations below are as used by the Equal Employment Opportunity Commission as social-political constructs and do not denote scientific definitions of anthropological origins. For the purposes of Vibrint's required reporting by the Federal government, an applicant may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging.

  • 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 tribal affiliation or community attachment.
  • Asian - 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, and Vietnam.
  • Black or African American – A person having origins in any of the Black racial groups of Africa.
  • Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
  • Native Hawaiian or Other Pacific Islander – A person having origins in any of the 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.
  • Two or More Races - All persons who identify with more than one of the above five races.
4. Ethnicity

Veteran Status

5. Veteran Status
  • Disabled Veteran refers to (1) a veteran 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 (2) a person who was discharged or released from active duty because of a service-connected disability.
    • Per the Jobs for Veterans Act of 2002, OFCCP’s Proposed Rule 41 CFR Part 60-300 dated January 20, 2006. This category is broader than the VEVRAA category of “special disabled veterans.”
  • Recently Separated Veteran refers to any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty.
    • Per ESA final rule dated 12/31/2005 amending 41 CFR-250 and VEVRAA by VBHCIA.
    • Per the Jobs for Veterans Act of 2002, OFCCP’s Proposed Rule 41 CFR Part 60-300 dated January 20, 2006: this category offers expanded coverage from one year period to three year period after discharge or release from active duty.
  • Other Protected Veteran refers to a person who served on active duty 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.
    • Per ESA final rule dated 12/31/2005 amending 41 CFR-250 by VEOA granting Other Protect Veterans VEVRAA status
  • Armed Forces Service Medal Veteran refers to any veteran who, while serving on active duty in Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
    • Per the Jobs for Veterans Act of 2002, OFCCP’s Proposed Rule 41 CFR Part 60-300 dated January 20, 2006.
  • Veteran of the Vietnam Era refers to a person who served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between February 28, 1961, and May 7, 1975 or between August 5, 1964, and May 7, 1975, in all other cases. The term also refers to a person who was discharged or released from active duty for a service-connected disability if any part of such active duty was performed in the Republic of Vietnam between February 28, 1961, and May 7, 1975, or between August 5, 1964, and May 7, 1975, in all other cases. NOTE: As a result of the Jobs for Veterans Act of 2002, OFCCP’s Proposed Rule 41 CFR Part 60-300 dated January 20, 2006 proposes elimination of the protected category of Veteran of the Vietnam Eras as defined under VEVRAA. However many Vietnam era veterans may remain covered in another category. Before selecting Veteran of the Vietnam Era please ensure you do not qualify as one of the continuing protected categories listed above. If selecting Veteran of the Vietnam Era as a veteran’s protected class, the veteran’s coverage may end per the above cited proposed legislation.
  • Individual with a Disability refers to a person who is covered by Section 503 of the Rehabilitation Act of 1973, as amended.
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