Applicant Information Form

Applicant Information Form

(Form 1 of 3)

Butler County Health Care Center, is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, or any other classification protected by Federal, state, or local law.

This information will be used strictly for statistical record-keeping purposes and will be kept confidential. Providing—or not providing—the gender/race/ethnic/veteran’s status information on this form will neither impact whether or not you are hired, nor will it affect your employment in any manner if you are hired. If you choose not to self-identify, you must select the declination box below to move forward with the application process. The person(s) making hiring and personnel decisions will not see this form.


Hispanic or Latino: A person of Cuban, Mexican, 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.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

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.

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 maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.  

Please indicate the posted position for which you are applying.
Please enter your full name.
Please check the race/ethnic groups with which you most identify.

Butler County Health Care Center is a federal contractor or subcontractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C 4212 ("VEVRAA"), which requires federal contractors/subcontractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.  These classifications are defined as follows:

  1. A "disabled veteran" is one of the following:
    1. A veteran of the U.S. military, ground, naval or air force 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 Secretary of Veteran Affairs; or
    2. A person who was discharged or released from active duty because of a service-connected disability.
  2. A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
  3. An "active duty  wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaing badge has been authorized under the laws administered by the Department of Defense.
  4. An "Armed Forces service medal veteran" means a veteran who, while serving 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.

If you believe you are a memeber of any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.  As a federal contractor or subcontractor subject to VEVRAA, we request this information to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRRA.  Your decision to provide the relevant information is purely voluntary on your part, and refusal to provide such information will not subject you to any adverse treatment.  The information will not be used in a manner inconsistent with VEVRAA, as amended.

The information will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Please check the appropriate response.