Your Invitation to Self-Identify Veteran and/or Disabled Status

This form is Voluntary and Confidential.

The Office of Affirmative Action welcomes you to the Arkansas State University workforce. You are invited to identify yourself voluntarily as a veteran and/or disabled person on the following form. This will help the university assure equal opportunity/affirmative action in its employment practices.

All information will be kept confidential; the data collected will be used in its aggregate form for the annual veteran’s employment report and the university’s affirmative action report. Both the Vietnam Era Veterans’ Readjustment Assistant Act of 1974, as amended (38 USC 4212), and the Rehabilitation Act of 1973, as amended (Section 503), provide specific policies for qualified protected veterans and qualified individuals with disabilities.

If you are a qualified protected veteran and would like to be considered under the university’s Affirmative Action Plan, or, if you have a disability and would like to be considered under the Americans with Disability Act, please tell us. You may inform us of your designation now or at any time in the future. This information will assist us in making accommodations which will assist you in your job duties.

Definitions of Disability and Veteran Categories

PERSON WITH A DISABILITY means any person who a) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, such as walking or speaking; b) has a record of such impairment or c) is regarded as having such an impairment.

VIETNAM-ERA VETERAN means any person who served on active military 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 with other than a dishonorable discharge.

OTHER PROTECTED VETERAN means any other veteran who served on active duty in the Armed Forces during a war or in a campaign or expedition for which a campaign badge has been authorized.

SPECIAL DISABLED VETERAN means a veteran who is entitled to compensation for a disability or a person who was discharged from active duty because of a service-connected disability.

ARMED FORCES SERVICE MEDAL VETERAN is a veteran who served 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).

NEWLY-SEPARATED VETERAN means any veteran who began employment with ASU within three years of being discharged or released from active duty in the U.S. military, ground, naval or air service.

(*) denotes required information.
I have read the aforementioned descriptions in this document and I further attest, by checking the appropriate space and signing below, that I am
Vietnam-Era Veteran Other Protected Veteran Special Disabled Veteran Newly-Separated Veteran in the past three years Not a Veteran or Person with a Disability
Discharge Date:
A person with a disability of one or more of the following types:
Visual Hearing Mobility Chronic Illness Other
* First Name:
Middle Initial:
* Last Name:
Date: