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Mental Health America

EEO-1 and VETS-100 Information

As a recipient of federal contract funds, MHA is required to complete certain filings with the federal government for Equal Employment Opportunity (EEO) purposes. Therefore, the organization invites you to self-identify with the information below. There are two primary sections to complete. Self-identification is a voluntary process.

Section One:

Name: ________________________________ Job Title: _________________________

Date of Hire or Date of Re-hire: _____________________

Sex: Please check one.

___Female

___Male

___Decline to self-identify

Ethnicity:

___Hispanic or Latino

___Not Hispanic or Latino

___Decline to Self-Identify

Race Categories

___White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)

___Black (A person having origins in any of the black racial groups of Africa)

___Native Hawaiian or Other Pacific Islander (A person having origins in Hawaii, Guam, Samoa, or other Pacific Islands)

___Asian (A person having origins in the Far East, Southeast Asia, Indian Subcontinent, including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

___American Indian or Alaskan Native (A person having origins in any of the original people of North, Central, and South America who maintains tribal affiliation or community attachment)

___Two or more races (Any person who identifies with two or more of the above races)

___Decline to self-identify

Section Two:

State status of US Military Service, are you a veteran, the categories defined as such:

Veteran of the Vietnam-era means a person who:

(1) Served on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964 and May 7, 1975 in all other cases; or

(2) Was a discharge or released from active duty for a service-connected disability if any part of such active duty was performed: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964, and May 7, 1975, in all other cases.

Special disabled veteran means:

(1) A veteran 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 Department of Veterans Affairs for a disability (I) rated at 30 percent of more, or (ii) rated at 10 or 20 percent if it has been determined that the individual has a serious employment disability; or

(2) A veteran who was discharged or released from active duty because of a service-connected disability

Other veteran means:

A veteran is one that served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. A complete list of campaigns can be viewed at

Veteran Information: Please check each category that applies to you. Remember that this is a voluntary request.

___Veteran of the Vietnam-Era

___Special Disabled Veteran

___Other Veteran

___ None

___Decline to self-identify

_______________________________________________________________________

Employee Signature and Date

Thank you!

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