Example Inc.

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Equal opportunity employer survey

Help us be an equal opportunity employer and answer the questions below. They are voluntary but it means a lot to us!

Example Inc. is committed to equal employment opportunity and nondiscrimination. Federal law requires us to reach out to, hire, and provide equal opportunity to qualified people without regard to race, color, religion sex, national origin, age, veteran status, genetic information, disability or any legally protected status. We are also subject to certain nondiscrimination recordkeeping and reporting requirements which require us to invite employees to voluntarily self-identify their race/ethnicity and gender.

To help us comply with our recordkeeping and reporting obligations under federal and state law, please answer the questions below. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the provisions of applicable laws, executive orders, and regulations.

Gender

Prefer not to tell

Female

Male

Race or ethnicity

I do not wish to identify at this time

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.

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.

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

American Indian or Alaskan 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 attachment.

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.

Veteran status

Why we ask about this?

Example Inc. wishes to voluntarily collect information about protected veteran status in order to voluntarily take affirmative action to employ protected veterans and advance them in employment. As described in 41 CFR § 60-300.2, the categories of protected veterans are defined as follows

A “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.

A “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.

An “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.

An “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.

Veteran status

I identify as one or more of the classifications of protected veteran listed above

I am NOT a protected veteran

I am NOT a veteran

I do not wish to identify at this time

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 04/30/2026

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury

Please check one of the boxes below:

I do not want to answer

Yes, I have a disability, or have had one in the past

No, I do not have a disability and have not had one in the past

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.

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Equal opportunity employer survey

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