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Employee Self-Identification

Please complete and submit the form below.

(To Be Completed By New Hires Only)
Geisinger Health System is an equal opportunity/affirmative action employer. As a federal contractor, we are required to keep records on the race, sex, and ethnicity of our employees and to file periodic reports with the government. Your participation is voluntary and will be kept confidential.
Part I - Sex, Race, Ethnicity
The following designations are those used by the Federal government. No other designations are available at this time. Please only mark one sex and one race/ethnic group.
PART II - Identification as Covered Veteran
Choose Appropriately
If you are a qualified individual with a disability, we would like to include you under the affirmative action program. It would assist us if you tell us about (1) any special methods, skills and procedures which qualify you for positions that you might not otherwise be able to do because of your disability so that you will be considered for any positions of that kind for which you apply and (2) the accommodations which we could make would enable you to perform the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of non-essential job functions, provisions of personal assistance services or other accommodations.
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This page was last modified on  12/09/2009