Your Name(Required) First Last Job Title(Required)Please SelectBehavior TechnicianRegistered Behavior TechnicianBCBAExecutive Level ManagerMid-Level Manager or SupervisorAdministrative SupportOtherCPT Location(Required)Please SelectBala CynwydCherry HillLakewoodNorthfieldGender(Required)Please SelectMaleFemaleTransgender, Non-Binary or Third GenderI choose not to self-identifyToday's Date(Required) MM slash DD slash YYYY What is your race/ethnicity? Please select from the drop-down list the one that describes the race/ethnicity category with which you primarily identify. The options are as follows: Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa. Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaska Native (Not Hispanic or Latino): 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. Two or More Races (Not Hispanic or Latino): a person who primarily identifies with two or more of the above race/ethnicity categories. Race/Ethnicity(Required)Please SelectHispanic or LatinoWhite (not Hispanic or Latino)Black or African American (not Hispanic or Latino)Asian (not Hispanic or Latino)Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)American Indian or Alaska Native (not Hispanic or Latino)Two or More Races (not Hispanic or Latino)I do not wish to discloseWhy are you being asked to complete this form? Because we do business with the state, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I 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: Blindness Deafness Cancer Diabetes Epilepsy Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation) Please Check One(Required) YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON’T HAVE A DISABILITY I DON’T WISH TO ANSWER NameThis field is for validation purposes and should be left unchanged.
