University of Hawai‘i at Hilo
Invitation to Self-Identify Disability or Veteran Status

The University of Hawai‘i is an affirmative action employer, committed to employing and advancing in employment qualified persons with disabilities, special disabled veterans, Vietnam era veterans, or any other veterans who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.  If you would like to be included in our affirmative action program, please let us know by completing this survey now or at any time in the future.  (Check all applicable items.)

Your response is voluntary. Declining to respond will not subject you to any adverse treatment.  Information you provide will be kept confidential, except that (1) supervisors and appropriate administrators may be informed regarding reasonable accommodations or work restrictions of persons with disabilities; (2) first aid personnel may be informed when, and to the extent appropriate, you have a condition that might require emergency treatment; and (3) certain information may be disclosed if required by a civil rights enforcement agency, regulation, or law.

  ("Disability" is a physical or mental impairment that substantially limits one or more major life activities.)

   

  (A veteran who is entitled to compensation by the Veterans Administration for a disability rated at 30% or more, or 10 or 20% under Section 3106 of Title 38 USC covering serious employment handicap, or a person who was discharged or released from active duty because of service-connected disability.)

  (A veteran who served on active duty for more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was honorably discharged or released sooner because of a service-related disability.)

Check DD-214 or call the EEO/AA Office for a list.

If you have a disability, do you require special assistance in the event of an emergency?  

in your present job that would enable you to perform the job properly and safely, such as special equipment, changes in the physical layout of the workplace, or changes in or assistance with certain duties related to the job?

If you have checked any of the above items, please fill out, print, sign and send this form to:
UH EEO/AA Office; PB4 Room 103; 200 W. Kawili Street; Hilo, HI 96720
Phone:  (808) 933-0824 (V/T)

- - Position Type:
I understand that my response is voluntary:
 
Signature Date

VETS-100 Form; revised 1/03