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Employee self-identification form

(Confidential when completed)

  • This form is designed to collect information on the composition of the Public Service workforce to comply with legislation on employment equity and to facilitate the planning and implementation of employment equity activities. Your response is voluntary and you may identify in more than one designated group.
  • The information you provide will be used in compiling statistics on employment equity in the federal Public Service. With your consent (see Box E), it may also be used by the employment equity co-ordinator of your department for human resource management purposes. This includes referral for training and developmental assignments and, in the case of persons with disabilities, facilitating appropriate accommodation in the workplace.
  • Employment equity information will be retained in the Employment Equity Data Bank (EEDB) of the Treasury Board Secretariat and its confidentiality is protected under the Privacy Act. You have the right to review and correct information about yourself and can be assured that it will not be used for unautho-rised purposes.
  • Step 1: Complete boxes A to E. In boxes B, C and D, refer to the definitions provided.
  • Step 2: Sign and date the form and return it to your department's EE coordinator.

Thank you for your cooperation

TBS/PPB 300-02432
TBS/SCT 330-78 (Rev. 1999-02)

A. Personal information

  • Family Name:
  • Given Name and Initial:
  • Department or Agency/Branch:
  • Telephone # (office):
  • Personal Record Identifier (PRI):
  • Gender:
    • Female
    • Male

B. A person with a disability... (i)

...has a long-term or recurring physical, mental, sensory, psychiatric or learning impairment and

  1. consider himself / herself to be disadvantaged in employment by reason of that impairement, or,

  2. believes that an employer or potential employer is likely to consider him/her to be disadvantaged in employment by reason of that impairment,

and includes persons whose functional limitations owing to their impairment have been accommodated in their current job or workplace.

Are you a person with a disability?

  • No
  • Yes, check all that apply
    • 11 Co-ordination or dexterity (difficulty using hands or arms, for example, grasping or handling a stapler or using a keyboard)
    • 12 Mobility (difficulty moving around, for example, from one office to another or up and down stairs)
    • 16 Blind or visual impairment (unable to see or difficulty seeing)
    • 19 Deaf or hard of hearing (unable to hear or difficulty hearing)
    • 13 Speech impairment (unable to speak or difficulty speaking and being understood)
    • 23 Other disability (including learning disabilities, developmental disabilities and all other types of disabilities)
    • (Please specify) _________________________________

C. An Aboriginal person...

...is a North American Indian or a member of a First Nation or who is Métis, or Inuit. North American Indians or members of a First Nation include status, treaty or registered Indians, as well as non-status and non-registered Indians.

Are you an Aboriginal person

  • No
  • Yes, check the appropriate circle
    • 03 North American Indian/First Nation
    • 02 Métis
    • 01 Inuit

D. A person in a visible minority...

...in Canada is someone (other than an Aboriginal person as defined in C above) who is non-white in colour/race, regardless of place of birth.

Are you in a visible group

  • No
  • Yes, check the circle which best describes your visible minority group or origin
    • 41 Black
    • 45 Chinese
    • 51 Filipino
    • 47 Japanese
    • 48 Korean
    • 56 South Asian/East Indian (including Indian from India;
      Bangladeshi; Pakistani; East Indian from Guyana, Trinidad, East Africa; etc.)
    • 58 Southeast Asian (including Burmese; Cambodian; Laotian;
      Thai; Vietnamese; etc.)
    • 57 Non-White West Asian, North African or Arab (including
      Egyptian; Libyan; Lebanese; Iranian; etc.)
    • 42 Non-White Latin American (including indigenous persons
      from Central and South America, etc.)
    • 44 Person of Mixed Origin (with one parent in one of the visible
      minority groups listed above)
    • 59 Other Visible Minority Group
      (Please specify)______________________________

E.

  • 99 The information in this form may be used for human resources management

__________________________
Signature

__________________________
Date (DD/MM/YY)

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