OMB Control Number 1250-0005
As an employer which may have an Affirmative Action obligation pursuant to Executive Order 11246, the Vietnam Era Veterans Readjustment Assistance Act, and the Rehabilitation Act, we must comply
with government regulations regarding the collection of demographic information about our employees and about those individuals being considered for employment with our organization.
We are required to invite individuals being considered for employment to self-identify as to gender, ethnicity, disability, or protected veteran status. If an offer of employment is extended,
individuals will be invited to self-identify as to disability or protected veteran status.
If you believe that you are covered by the above Acts, the Company invites you to self-identify for consideration under its Affirmative Action Programs. Provision of this information is voluntary
and refusal to provide it will not subject the applicant or employee to adverse treatment. Further, if provided, the information will be kept confidential and used only in accordance with the
Acts and regulations.
-- Select Gender --
-- Select Ethnicity --
American Indian/Alaskan Native
Black of African American
Hawaiian or Pacific Islander
Hispanic or Latino
Two or More Races
American Indian or Alaskan Native: All persons having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Asian: 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.
Black or African American (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.
Two or More Races: A person who primarily identifies with two or more of the above race/ethnicity categories.
White (Not of Hispanic Origin): All persons having origins in any of the original people of Europe, North Africa, or the Middle East.
Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
Because we do business with the government, we must reach out 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.
How do I know if I 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:
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
Missing limbs or partially missing limbs
Multiple sclerosis (MS)
Obsessive compulsive disorder
Post-traumatic stress disorder (PTSD)
Please select one below:
YES, I have a disability (or previously had a disability).
NO, I don't have a disability.
I don't wish to answer.
Reasonable Accommodation Notice
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.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
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
Paul Mueller Company is a Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of2002, 38 U.S.C. 4212 ("VEVRAA"),
which requires Government contractors to take affirmative action to employ and advance in employment:(!) 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 follows:
A "disabled veteran" is one of the following:
A veteran of the U.S. military, ground, naval or air force 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 Secretary of Veterans Affairs; or
A person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military,
ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in
a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed Forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a
United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
If you believe you are a member of any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor
subject to VEVRAA, we request this information to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Your decision to
provide the relevant information is purely voluntary on your part, and refusal to provide such information will not subject you to any adverse treatment. The information will
not be used in a manner inconsistent with VEVRAA, as amended.
The information will be kept confidential, except that (i) supervisors and managers may
be informed regarding restrictions on the work or duties of disabled veterans, and regarding
necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the
extent appropriate, if you have a condition that might require emergency treatment; and (iii)
Government officials engaged in enforcing laws administered by the Office of Federal Contract
Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.