Name * First Name Last Name Date MM DD YYYY Sex Male Female I prefer not to self-identify Race/Ethnicity: Definitions Provided by EEOC RACE/ETHNICITY DEFINITIONS: 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): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands American Indian or Alaska 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): Persons who identify with two or more race categories named above. White or Latino White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Two or More Races I prefer not to self-identify. Veteran Status I self-identity as a Veteran I do not self-identify as a Veteran I prefer not to self-identify. Disability Status 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, or HIV/AIDS • Blind or low vision • Cancer (past or present) • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or serious difficulty hearing • Depression or anxiety • 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, or 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 • Traumatic brain injury • Short stature (dwarfism) Yes, I have a disability, or a history/record of having a disability. No, I don’t have a disability, or a history/record of having a disability. I prefer not to self-identify. Thank you!
