Hudson County Community College - Part-Time Administrative Assistant,
Facilities Department

Voluntary Self-Identification Form

Hudson County Community College does not discriminate on the basis of race, color, gender, religion, age, marital status, pregnancy, sexual orientation, national or ethnic origin, disability, genetic information, gender identity or expression, or veteran status in any program or activity administered by the College.

The information you provide will remain confidential. The completed survey contains no reference to your name and it will be maintained separately from your applicant file in the compliance office or other designated location. Applicant Data Forms, without names, will be retained in the compliance office or other designated location for the purpose of compiling information about the applicant pool, and to assist the College in the evaluation/enhancement of its affirmative action recruitment efforts.

Question Title

* 1. What is your gender?

Female

Male

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* 2. Are you of Hispanic or Latino origin or descent?

Yes, Hispanic or Latino

No, not Hispanic or Latino

Question Title

* 3. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

Question Title

* 4. Are you a person living with a disability?

Disability means any person who:

has a physical or mental impairment which substantially limits one or more major life activities;

has a record of such impairment; or

is regarded as having such an impairment

Yes

Question Title

* 5. Veteran Status
(Please check all that apply)

Disabled Veteran -(1) a veteran of the U.S. military, ground, naval or air service 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 (2) a person who was discharged or released from active duty because of a service-connected disability.

Other Protected Veteran- 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 campaign badge has been authorized.

Armed Forces Service Medal Veteran -a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p.159).

Recently Separated Veteran- a veteran during the three-year period beginning on the date of the such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.

I do not wish to self identify

I am not a veteran

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* 6. What prompted you to apply to Hudson County Community College.

Personal Contact (please provide name of contact in the comment box below)

Notice in Professional Journal (please provide name of journal in the comment box below)

Newspaper Advertisement (please provide name of newspaper in the comment box below)

Placement Service (please provide name of placement service in the comment box below)

Other (please describe in comment box below)

Please provide answer to above question:

Question Title

* 1. What is your gender?

Question Title

* 2. Are you of Hispanic or Latino origin or descent?

Question Title

* 3. Which race/ethnicity best describes you? (Please choose only one.)

Question Title

* 4. Are you a person living with a disability?Disability means any person who: has a physical or mental impairment which substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such an impairment

Question Title

* 5. Veteran Status(Please check all that apply)

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* 6. What prompted you to apply to Hudson County Community College.

Question Title

* 7. Please provide the title of the position you are applying for:

* 4. Are you a person living with a disability?

Disability means any person who:

has a physical or mental impairment which substantially limits one or more major life activities;

has a record of such impairment; or

is regarded as having such an impairment

* 5. Veteran Status
(Please check all that apply)