Voluntary Self-Identification Form

Montclair State University is subject to certain governmental record-keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws and regulations, it is important that our record-keeping and reporting information is accurate. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be entered into Montclair State University’s Human Resources Information System and may be used in accordance with the applicable laws and regulations concerning equal employment opportunity. If you are a job candidate, please be advised that this information will be kept separate from your application materials and will not be used in evaluation of candidates. If you already work for Montclair State University, your answers will not be used against you in any way.
Position applied for: V#

Position Title:

(Optional) Your Name:

How did you hear of our vacancy?
Chronicle of Higher Education
Sunday Star Ledger
MSU/HR Website
Announcement posted on a college or university campus
Friend or acquaintance
MSU employee
other:

Gender:

Without regard to race, is your ethnicity Hispanic or Latino? (A person is considered Hispanic or Latino if Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture of origin, regardless of race.)
Hispanic or Latino
Not Hispanic or Latino

Without regard to ethnicity, please check all racial categories that apply to you.
WHITE (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
BLACK or AFRICAN AMERICAN (A person having origins in any of the black racial groups of Africa.)
ASIAN (A person having origins in any of the original peoples of the Far East, Southeast Asia, and the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
AMERICAN INDIAN OR ALASKA NATIVE (A person having origins in any of the peoples of North and South American, including Central America, and who maintains tribal affiliation or community recognition.)
I do not wish to self-identify.

Are you a Vietnam-era veteran? [Note: This category is applicable to you if you (A) served on active duty for more than 180 days and you were discharged or released with other than a dishonorable discharge, or (B) you were discharged or released from active duty for a service-connected disability, if any part of such active duty was performed: (i) in the Republic of Vietnam between 2/28/61 and 5/7/75, or (ii) in all other areas between 8/5/64 and 5/7/75.]
Yes
No

Are you a special disabled veteran? [Note: This category is applicable to you if you are (A) entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by Veteran’s Administration for disability (1) rated at 30% or more, or (2) rated at 10% or 20% as determined under section 1506 of Title 38, U.S.C., to have a serious employment disability, or (B) discharged/released from active duty for a disability incurred or aggravated in the line of duty.]
Yes
No

Are you an otherwise eligible veteran? [Note: This category is applicable to you if you are a veteran who has served on active duty during a war, or in a campaign or expedition for which a campaign badge has been authorized.]
Yes
No

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this information is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)

Please check one of the boxes below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Examples of reasonable accommodations include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. You may contact the Division of Human Resources at (973) 655-5293 for additional information.