EEO SELF-IDENTIFICATION DATA FOR NEW UWSP EMPLOYEES

Please complete and return this form to UWSP Academic Affairs. Please print legibly in blue or black ink.  (required)

All sections below are optional.

Part I:  Identification as Covered Veteran (Check ALL that Apply)

_____   Veteran of Vietnam Era.  This term means a person who served on active duty for 180 days or more, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such duty occurred:  (a) in the Republic of Vietnam between 2-28-61 and 5-7-75, OR (b) between 8-5-64 and 5-7-75 in all other cases, OR (c) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed in the place/periods described in "a" and "b" above.

_____   Special Disabled Veteran.  This term means a veteran 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 Department of Veterans Affairs for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20 percent in the case of a veteran who has been determined under 38 U.S.C. 3106 to have a serious employment handicap, OR a person who was discharged or released from active duty because of a service-connected disability.

_____   Other Veteran.  This term means a veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

_____   Decline to disclose.

Part II:  Identification of a Disability (Check ALL that Apply)

Any person who (1) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (2) has a record of such impairment; or, (3) is regarded as having such an impairment.

The University of Wisconsin – Stevens Point is an equal opportunity employer committed to the policies and principles of equity and affirmative action.  The University is required by federal law to gather this information for reporting purposes.  Your participation is voluntary, and the information you provide will be kept confidential and only used as summary data.

GENDER:                Male ______ Female ______ Decline to Disclose ______

Signature:  ________________________________________________ Date:  ____________________

FOR OFFICE USE ONLY:

S Drive: Folder: UWSP Employee Self-Reporting Data Sheet  New UWSP Employee Self-Reporting Data Sheet 10-30-08