Affirmative Action Program Data
Human Resources 650-3774
Western Washington University is an equal opportunity and affirmative action employer. As a government contractor, the University is required by applicable laws to maintain data regarding employees' race, ethnicity, gender, veteran status and disability status. The University therefore invites new employees to provide the following information. Submission of this information is voluntary; refusal to provide the requested information will not subject you to any adverse treatment. This information will be kept confidential and used in conjunction with the University's affirmative action program in compliance with Federal Executive Order 11246, the Vietnam Era Veterans' Readjustment Assistance Act of 1974 (VEVRAA) as amended by the Jobs for Veterans Act of 2002 (38 U.S.C. 4212), the Rehabilitation Act of 1973, Washington State Executive Order 93-07, and all applicable implementing regulations, and will not be used in any way that is inconsistent with these laws.
Employee ID (if applicable):
Ethnicity, Race and Gender
Are you Hispanic or Latino?
With which race(s), if any, do you self-identify? Check all that apply. (
American Indian or Alaska Native
Black or African American
Native Hawaiian or other Pacific Islander
Government contractors are required 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 a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified "protected veteran" category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.
I belong to one or more of the following classifications of protected veterans (choose all that apply):
Active Wartime or Campaign Badge Veteran
Armed Forces Service Medal Veteran
Date of Discharge:
*NOTE: If the Date of Discharge entered is within the past three years, then you are
selecting a classification as a 'recently separated veteran.'
I am a protected veteran, but I choose not to self-identify the classifications to which
I am a veteran, but I do not identify with any of the classifications of protected veterans
I am not a veteran.
If you are a disabled veteran, you are encouraged to contact Disability Services in Human Resources at (360) 650-3771 or
to inform the University if there are reasonable accommodations we could make that would enable you to perform the essential functions of your job.
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal
employment opportunity to qualified people with disabilities. We are also required to
measure our progress toward having at least 7% of our workforce be individuals with
disabilities. To do this, we must ask applicants and employees if they have a disability
or have ever had a disability. Because a person may become disabled at any time, we
ask all of our employees to update their information at least every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you
will choose to do so. Your answer will be maintained confidentially and not be seen by
selecting officials or anyone else involved in making personnel decisions. Completing
the form will not negatively impact you in any way, regardless of whether you have self-
identified in the past. For more information about this form or the equal employment
obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the
U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP)
How do you know if you 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:
Autoimmune disorder, for example,
lupus, fibromyalgia, rheumatoid
arthritis, or HIV/AIDS
Blind or low vision
Cardiovascular or heart disease
Deaf or hard of hearing
Depression or anxiety
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Missing limbs or partially missing
Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
Psychiatric condition, for example,
bipolar disorder, schizophrenia,
PTSD, or major depression
Please check one of the boxes below:
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don't Have A Disability, Or A History/Record Of Having A Disability
I Don't Wish To Answer
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.
Signatures and Attachments
The submitter may optionally enter their email address below. Press SUBMIT to send it.
Your Email Address: