Prospective Employees Self Identification Form - Dalhousie University

Self-Identification QuestionnaireApplicants for Academic PositionsThank you for your interest in a position at Dalhousie University. As part of the recruitment process we ask that youprovide us with the following information. Please return this form as soon as possible.Name:_________________________________Rank and Title of Position applied for:________________________________________________________________________________Date:_________________________________________Department:___________________________________Faculty: _______________________________________Please address this form to the:Department and Faculty which has your applicationc/o Search Committee (Rank and Title of the Position Applied for)Dalhousie University, Halifax, Nova Scotia, Canada, B3H 4R2Section 1 - Statement of Canadian Status (Required Information)The University must comply with federal government requirements regarding recruitment of foreign academics andgive priority to qualified Canadian Citizens and permanent residents, whether in Canada or abroad, unless theposition does not require employment validation from Human Resources Development Canada (HRDC)Are you a Canadian Citizen or permanent resident of Canada? Yes NoSignature: ______________________________________Section 2 – Self-Identification (Voluntary Information)1. Sex Female Male2. Racially Visible PersonsFor the purposes of employment equity, “members of a racially visible group” means persons, other than Aboriginalpeoples, who are non-Caucasian in race or non-white in colour. The racially visible groups include:- Black (eg. African, American, Canadian, Caribbean)- East Asian (eg. Chinese, Japanese, Korean, Polynesian)- South Asian (eg. Indian, Pakistani, Sri Lankan, Bangladeshi)- Southeast Asian (eg. Burmese, Cambodian, Filipino, Laotian, Malaysian, Thai, Vietnamese)- West Asian and Arab (eg. Afghani, Armenian, Egyptian, Iranian, Iraqi, Lebanese, Jordanian, Palestinian, Syrian,Turk)- South or Central Amer-Indian- Other (including mixed ancestry)Based on this definition, do you consider yourself a member of a racially visible group?Yes No Please specify:_________________________________Do you consider yourself Indigenous Black to Nova Scotia?YesNo

3. Persons with a disabilityFor the purposes of employment equity, “persons with a disability” means persons who have a long-term orrecurring physical, mental, sensory, psychiatric or learning impairment and who:- consider themselves to be disadvantaged in employment by reason of that impairment, or- believe that an employer or potential employer is likely to consider them to be disadvantaged in employment byreason of that impairment, and includes persons whose functional limitations owing to their impairment havebeen accommodated in their current job or workplace.Based on this definition, do you consider yourself to be a person with a disability?YesNo4. Aboriginal peoplesFor the purposes of employment equity, “Aboriginal peoples” means person who are First Nations, Inuit or Métis.Based on this definition, do you consider yourself an Aboriginal person?YesNoAre you Mi’kmaq?YesNoThank you for taking part in this survey.If you are hired, you will be asked to complete a more detailed questionnaire.5. Comments?This questionnaire is also available in other formats. If you require another format, contact the address below.For further information on employment equity, please contact:Office of Human Rights, Equity & Harassment Prevention(902) 494-6672Email: hrehp@Dal.CaWebsite: www.hrehp.dal.ca