Employee Information Form CITY OF BROCKTON Department of Human Resources The City of Brockton would like to ensure that employee information is correct in the system. Please complete the following (if applicable) and return to Human Resources so we may update your information accordingly. Employee Number First Name(Required) Middle Last Name(Required) Department(Required) Telephone numberEmail(Required) Address*(Required) City(Required) State(Required) Zip(Required) Mailing Address City State Zip *If you are an employee who is currently enrolled in Health Insurance with the City of Brockton and has a change of address, you will also need to complete one of the following depending on your coverage: Blue Cross Blue Shield (BCBS) - Please complete Section 2 only Harvard Pilgrim Health Care (HPHC) - Navigate to: REASONS FOR CHANGES, select OTHER and state "Address Change". EMERGENCY CONTACTSPrimary Contact Name Address Telephone Relationship Secondary Contact Name Address Telephone Relationship Educational Data Educational Level ( Degree, Major, School Name, Year Awarded)High School Degree HS Major HS Name HS Year Awarded College Degree College Major College Name College Year Awarded Masters Degree Masters Major Masters School Name Masters Year Awarded Technical Degree Technical Major Technical School Name Technical Year Awarded Other Degree Other Major Other School Name Other Year Awarded Signature(Required)Date(Required) Equal Opportunity Employment Self-Identify Data Form The City of Brockton is an Equal Opportunity Employer with a commitment to recruitment and retention of a diverse and inclusive community. Collection of the following information on gender, race/ethnicity, disability and veteran status is in compliance with Federal laws and regulations, executive orders and applicable State laws and regulations. Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin. The information that you submit will remain confidential and be used by the City only for statistical and required reporting purposes. Completion of this form is voluntary; failure to provide this information will not adversely affect your employment and/or employment consideration.Full Name Date of Hire Department Position Title Gender Male Female Non-Binary Don't wish to identify ETHNICITY: Are you of Hispanic or Latino Origin? Yes No (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) RACE: Select one or more that apply: American Indian or Alaskan Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) White or Caucasian (Not Hispanic or Latino) Two or more I choose not to ID American Indian or Alaskan Native - 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. Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Bangladesh, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Sri Lanka, Thailand, and Vietnam. Black or African American - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White or Caucasian - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Two or more - All persons who identify with more than one of the above. I choose not to ID - All persons not wishing to self identify race and/or ethnicity. Invitation to Voluntarily Self-Identify Veteran Status We ask that you please consider completing this Invitation to Voluntarily Self-Identify Veteran Status to help us fulfill our commitments to equal opportunity and affirmative action and to meet our obligations as a government contractor under the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). “Protected veteran†categories are identified in VEVRAA. This statute requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. VEVRAA defines these classifications as follows: Protected Veteran classifications are defined as follows: A "disabled veteran" is one of the following: 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 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. Self-Identification Are you a protected veteran? I am a protected veteran I am not a protected veteran I choose not to identify SignatureDate Voluntary Self-Identification of DisabilityName Date Employee ID Why are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. dentifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you 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: Autism Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS Blind or low vision Cancer Cardiovascular or heart disease Celiac disease Cerebral palsy Deaf or hard of hearing Depression or anxiety Diabetes Epilepsy Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome Intellectual disability Missing limbs or partially missing limbs Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Please check one of the boxes below: Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability I don't wish to answer 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.
