Affirmative Action Voluntary Self Identification Forms
InSource Solutions (the “Company”) is an equal opportunity employer and does not discriminate on the basis of race, color, sex (including pregnancy, sexual orientation, gender identity or transgender status), age, religion, ancestry, national origin, disability, or status protected veteran. As an equal opportunity employer, the Company complies with all relevant government regulations and affirmative action responsibilities. Solely to help us with record keeping, reporting, and other legal requirements, we offer you the opportunity to complete this self-identification form. Submission of this information is voluntary. Whether you provide this information or not, you will not be subject to adverse treatment.
The Company maintains affirmative action plans for persons with disabilities and protected veterans. These plans, or portions thereof, that will enable you to avail yourself of their benefits, are available for inspection by contacting Julie Joyce, Affirmative Action Administrator, during normal business hours.
Please complete all 4 portions. If you choose not to self-identify, please check that box and sign.
Part I: Your Race and Gender
Part 2: Your Veteran Status
DEFINITION OF THE TERMS “PROTECTED VETERAN,” means a veteran who is protected under the nondiscrimination and affirmative action provisions of the Vietnam Veterans’ Readjustment Assistance Act, 38 U.S.C. 4212; specifically a veteran who may be classified as an active duty wartime or campaign badge veteran, disabled veteran, Armed Forces service medal veteran, or recently separated veteran,
Part 3: Do you have a disability?
Because we do business with the government, we are required to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
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:
- Bipolar Disorder
- Cerebral Palsy
- Impairments requiring the use of a wheelchair.
- Intellectual disability (previously called mental retardation)
- Major Depression
- Missing limbs or partially missing limbs
- Muscular dystrophy
- Multiple sclerosis (MS)
- Obsessive Compulsive disorder
- Post-traumatic stress disorder (PTSD)
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
Please contact email@example.com for assistance.
Part 4: Your Acknowledgement
The provision of this information is on a voluntary basis. This document is maintained in a separate location for affirmative action program use and will not be included in the personnel file of any employee.
I am given the opportunity to participate in the self-identification process: