Affirmative Action Survey Form

Dear Applicant:

Thank you for your interest in employment with California State University, Northridge.

Our University is interested in reaching the broadest possible group of qualified applicants. This survey has been devised to assist us in monitoring the effectiveness of our recruitment efforts, and to assist in collecting data which is required for compliance with State, Federal and University reporting requirements. Your cooperation in the timely completion and return of this form is most appreciated. A self-addressed stamped envelope has been enclosed for your convenience. While your reply will be most helpful to us in carrying out our administrative responsibilities, return of this form is entirely voluntary. This form will be retained in the Office of Equity and Diversity and will not be made available to the department.

Thank you for your cooperation!

AREA OF RESIDENCE: Southern California Northern California Other

Please indicate Other______________________________________________

GENDER: Female Male AGE 40 OR OLDER: Yes No DISABLED: Yes No

ETHNIC ORIGIN: Please click the box corresponding to the ethnic origin with which you most closely identify. Click one box only.

Black (Not Hispanic) – Person of Black African descent.

Asian – Person of Japanese, Chinese, Korean, Vietnamese, Asian Indian, Thai or similar descent other than Pacific Islander or Filipino.

Hispanic/Latino – Person of Mexican, Puerto Rican, Cuban, South or Central American or other Spanish descent.

White (Not Hispanic) – Person of European, North African or Middle Eastern descent.

Pacific Islander – Person of Hawaiian, Samoan, Guamanian, Polynesian, Fiji or Tahitian descent.

Native American – Person of American Indian, Eskimo, or persons of origins in any of the original peoples of North America.

Filipino – Person of Filipino descent.

Other / Unknown.

HOW DID YOU LEARN ABOUT THIS VACANCY?

Advertisement Where?

Bulletin Announcement Where?

Professional Meeting Which?

Social/Service Agency Which?

Word of Mouth Colleague Relative Friend Northridge Faculty Member Other Person

Other source Which?

CHECK IF APPLICABLE:

VETERAN: Period of service: From: ________________ To: _________________

DISABLED VETERAN: Are you receiving 30% or more compensation? Yes No N/A

Faculty Hire Number Identification (To be filled in by the department prior to mailing):

Faculty Hire No.: _____________________ Department: ______________________________________________