AFFIRMATIVE ACTION DATA QUESTIONNAIRE

Office of Diversity & Equity

In an effort to comply with State and Federal requirements, we are requesting that you take a moment to complete this questionnaire. Disclosure of the information is voluntary and will not affect your opportunity for employment, or terms or conditions of employment. The information provided will be used for State and Federal required workforce reporting purposes only and maintained in a confidential manner separate from your application.

Name:

Email:

Sex:

MaleFemale

Race or National Origin (check one):

Black - (not of Hispanic origin) all persons having origins in any of the Black racial groups of Africa.Hispanic or Latino - all persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.White - (not of Hispanic origin) all persons having origins in any of the original peoples of Europe, North Africa or the Middle EastAmerican Indian or Alaskan Native - all persons having origins in any of the original people of North and South America, and who maintain cultural identification through tribal affiliation or community affiliation.Asian - all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. The area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.Two or more race categories - all persons who identify with more than one of the above.

Position for which you are applying:

Search #:

How were you referred to us?

Newspaper or journal advertisement Specify which one(s)

Professional Associations Specify which one(s)

Employee Referral

Internet Posting (please specify?

The security of all members of the campus community is of vital concern to �Թ�ͷ��. In compliance with the Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act, information concerning campus security can be found online at��/police/��or��may be requested from the Western Connecticut��State��University’s Police Department (203-838-9304)