Voluntary Self Disclosure Form

Race/Ethnicity
Please check one that describes the race/ethnicity category with which you primarily identify.

Hispanic or Latino: a person of Mexican, Puerto Rican, Cuban, Central or South African, or other Spanish culture or origin, regardless of ethnicity.

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

Black or African American (not Hispanic or Latino): a person having origins in any of the black ethnic groups of Africa.

Native Hawaiian or other 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 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.

American Indian 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 maintain 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.

Disability Status
Definition: An individual with a disability is defined by the ADA (Americans with Disabilities Act) as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.

Do you have a disability? Yes No

If yes, can you perform all of the essential functions of the job with reasonable accommodations? Yes No

If no, what kind of accommodations do you require?

Veteran Status

Are you a veteran? Yes No

Latest military discharge date:

If yes, please check ALL that describe your veteran status.

SPECIAL DISABLED VETERAN (A) A veteran who is entitled to compensation (or who, but for receipt of military retired pay, would be entitled to compensation) under laws administered by the Department of Veteran Affairs for a disability rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment disability. OR (B) A veteran who was discharged or released from active duty because of a service-connected disability.

VIETNAM-ERA VETERAN (A) A veteran who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1967, and May 7, 1975, and was discharged or released with other than a dishonorable discharge. OR (B) A veteran who was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964, and May 7, 1975. OR (C) A veteran who served on active duty for more than 180 days and served in the Republic of Vietnam between February 28, 1961, and May 7, 1975.

OTHER PROTECTED VETERAN A veteran in one of the following groups: (A) Veterans who served in a “war.” OR (B) Veterans whose service in a campaign or expedition for which a campaign badge has been authorized or an expeditionary medal has been awarded. This includes a number of military engagements.

RECENTLY SEPARATED VETERAN Any veteran who began employment at OHCC within one year of being discharged or released from active duty in the U.S. military, ground, naval, or air force.

Gender Male Female

Name