EEO-1 Voluntary Self Identification Form

[Editor's Note: Employers may voluntarily choose to report employee demographic data for non-binary employees – that is, employees who do not identify as exclusively male or female. Employers should consider whether the nonbinary option should be removed from the voluntary self-identification form below for use in their organization.]

The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report.

Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department.

If you choose not to self-identify at this time, the federal government requires [Company Name] to determine this information by visual survey and/or other available information.

NAME: __________________________________

JOB TITLE: ________________________________

DATE COMPLETED: ___________________________

GENDER:
(Please check one of the options below)

_____ Male

_____ Female

_____ Nonbinary

RACE/ETHNICITY:
(Please check one of the descriptions below corresponding to the ethnic group with which you identify.)

___ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

___ White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

___ Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.

___ Native Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.

___ Asian (Not Hispanic or Latino): 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.

___ Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

___ Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.

___ I do not wish to disclose.