University of Southern Maine

VOLUNTARY AFFIRMATIVE ACTION INFORMATION SURVEY

Dear Applicant:

The University of Southern Maine seeks to affirmatively recruit a diverse pool of applicants and finalists for all available positions. I need your assistance in determining the success of our recruitment efforts. By filling out this form and sending it back to me, I am able to evaluate the success of our efforts.

If you have any questions about this form, or any other questions about USM or the Portland area, please call me at (207)780-5094 or TDD (207)780-5646. You may do so confidentially and without using your name.

Sincerely,

Kathleen Roberts, Executive Director
Office of Campus Diversity and Equity
PO Box 9300
Portland, ME 04104-9300

Name:__________________________________________________________________________

Position applied for:____________________________________________Position #__________

Gender: Female ______ Male ______

Racial/Ethnic Data:

Please check one of the following racial/ethnic groups. For definitions of groups, please refer to reverse side of this page.

______ Black                                                  ______ White                                              ______ Hispanic

______ American Indian/Alaskan Native          ______ Asian/Pacific Islands

Veteran Status:

Please check if any of the following are applicable. For definitions, please refer to reverse side of this page.

______ Vietnam Era Veteran              ______ Disabled Veteran             ______ Veteran

Disability Status:

Please refer to the definition following.

Do any of the conditions as defined apply to you? ______ Yes ______ No

WHITE:

A person having origins in any of the peoples of Europe, North Africa, or the Middle East who is not of Hispanic origin.

BLACK:

A person having origins in any of the black racial groups of Africa who is not of Hispanic origin.

HISPANIC:

A person of Mexican, Puerto Rican, Cuban, South American, or other Spanish culture or origin, regardless of race.

ASIAN OR PACIFIC ISLANDER:

A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes for example, China, India, Japan, Korea, the Philippines Island, and Samoa.

AMERICAN INDIAN OR ALASKAN NATIVE:

A person having origins in any or the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

VIETNAM ERA VETERAN:

Veteran of the Vietnam era means a person who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge or 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.

DISABLED VETERAN:

A person (1) entitled to disability compensation from the Veteran's Administration for a disability rating of 30% or more, or (2) whose release from active duty was for a disability incurred or aggravated in the line of duty.

DEFINITIONS FOR DISABLING CONDITIONS

Any person who:

(1) has a physical or mental impairment which substantially limits one or more of such person's major life activities,
(2) has a record of such impairment or,
(3) is regarded as having such an impairment

Please note:  The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act of 1998 requires universities to disclose three years of statistics regarding campus crime, including off campus buildings the University owns and on public property adjacent to the campuses in Portland, Gorham and Lewiston.   Our report (Safety and Security Information Report) also includes our policies for campus security, such as those concerning alcohol and drug use, crime prevention, the reporting of crimes and sexual assaults and other related matters.   You may obtain a copy from the web or by calling the Office of Community Standards at (207) 780-5242 to request a paper copy.