Why are you being asked to complete this form?

Because we do business with hospitals who also do business with the government for compliance purpose. We must reach out to, hire, and provide equal opportunity to qualified people with disabilities by law. 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 contractors, clients, and 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:

Please select one of the options below:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

---

Definitions

MedTrust Staffing Company is a contractor subject to Section 4212 of the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by law. Veterans are also encouraged to apply for staffing placement. You are encouraged to review, update, and designate any applicable veteran status by clicking the appropriate options below. Providing this information will help support MedTrust Staffing Company’s Affirmative Action/Equal Employment Opportunity compliance and ongoing diversity efforts and programs.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Information you submit will be treated as confidential. Disclosure and usage will be limited to: (i) supervisors and managers who need to know about any limitations on work duties; (ii) first aid and safety personnel when necessary; (iii) government officials auditing compliance with applicable laws, (iv) disclosure where otherwise required by law; and (v) in support of Affirmative Action/Equal Employment Opportunity regulations and MedTrust Staffing Company.

Disabled Veteran - (1) a veteran of the U.S. military, ground, naval or air service 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 Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service connected disability.

Recently Separated Veteran - A 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.

Active Duty Wartime or Campaign Badge Veteran - 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 campaign badge has been authorized under the laws administered by the Department of Defense.

Armed Forces Service Medal Veteran - 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.

Vietnam Veteran - A veteran who has served honorably in the Republic of Vietnam and does not identify with any other veteran category.

Veteran, any other type - A veteran who has served honorably in the US armed forces, including National Guard/Reserves regardless of activation status, and does not identify with any other veteran category.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

Self-Identification

Reasonable Accommodations Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

---

Diversity

To assist MedTrust Staffing Company in meeting governmental reporting requirements and to evaluate our selection processes, we invite you to complete the following information. Please note that submission of this information is voluntary and refusal to complete this information will not subject you to adverse treatment. The information you provide is confidential and will be used for data reporting requirements and will not be utilized in making any employment decisions. Thank you for your cooperation.

MedTrust Staffing Companyconsiders all job seekers for employment without regard to race, color, gender, national origin, religion, age, sexual orientation, gender identity, genetic information, physical or mental disability, pregnancy, marital status, status as a protected veteran, or any other status protected by federal, state, or local law.

Gender

Race/Ethnicity

Based upon the federal government's reporting requirements and definitions of race and ethnicity, please select one of the categories below:

Hispanic or Latino (Ethnicity): A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

American Indian/Alaskan Native (Race): A person with origins in any of the original peoples of North America who maintains cultural identification through tribal affiliation or community recognition, who is not of Hispanic or Latino origin.

Asian (Race): A person with origins in the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, for example, China, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam, who is not of Hispanic or Latino origin.

Black or African American (Race): A person with origins in any of the black racial groups of Africa, who is not of Hispanic or Latino origin.

Native Hawaiian or Other Pacific Islander (Race): A person with origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands, who is not of Hispanic or Latino origin.

White (Race): A person with origins in any of the original peoples of Europe, North Africa, or the Middle East, who is not of Hispanic or Latino origin.

Two or More Races: A person who identifies with more than one of the above five races, who is not of Hispanic or Latino origin.