LAST STEP: PERSONAL DATA and SELF-IDENTIFICATION
St. Louis College of Pharmacy is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with
these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to
any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including
those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
Position Applied For:
Date of Birth:
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1. This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. § 4212 (VEVRAA), which requires Government contractors to
take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications
are defined as follows:
"disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service 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 a person who was discharged or released from active duty because of a service-connected disability.
"recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service 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.
"Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal
was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled
to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.
For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
2. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the
effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
I AM A VETERAN, BUT NOT IDENTIFIED IN ONE OF THE GROUPS ABOVE
I AM NOT A PROTECTED VETERAN
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Why are you being asked to complete this form?
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 form 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.
How do I know if I have a disability?
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:
• Cerebral palsy
• 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. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable
accommodation 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.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs
(OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about
5 minutes to complete.