Summary: SEE REVERSE FOR PRIVACY NOTIFICATIONS OVER
RETN: Destroy after data entry pursuant to
DEMOGRAPHIC DATA TRANSMITTAL
U5605 (R6/10) University of California Human Resources
All questions regarding ethnic, veterans, or disabled identification should be directed to the campus Equal Employment
Opportunity/Affirmative Action Office.
EMPLOYEE NAME (LAST, FIRST, MIDDLE INITIAL) CAMPUS DEPARTMENT/ORGANIZATIONAL UNIT BIRTHDATE
MO DY YR
As a Federal contractor, the University of California is required to collect and report information regarding the ethnic and racial background of
its employees (see reverse for Privacy Notification Statement). Please self-identify your ethnicity and race by completing Sections 1A and 1B
of this form.
Additionally, to comply with Federal recordkeeping mandates, the University of California is required to monitor the number of its employees
who have a disability or are protected veterans. Please self-identify your status as disabled individual and/or protected veteran by completing
Section 2 and/or Section 3 of this form as applicable to you.
1. ETHNICITY AND RACE
Please complete Sections 1A and 1B below. The information must be collected in both sections in order for the University to comply with
U.S. Department of Education requirements for the collection and reporting of ethnicity and race data as well as Affirmative Action program
reporting requirements. The University of California will not be able to accurately report your information if both sections are not