Form CALHR1070 "State Employee Race/Ethnicity Questionnaire" - California

What Is Form CALHR1070?

This is a legal form that was released by the California Department of Human Resources - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the California Department of Human Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CALHR1070 by clicking the link below or browse more documents and templates provided by the California Department of Human Resources.

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Download Form CALHR1070 "State Employee Race/Ethnicity Questionnaire" - California

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State Employee Race/Ethnicity Questionnaire
California Department of Human Resources
State of California
INSTRUCTIONS:
All new/rehired employees are requested to voluntarily self-identify their race/ethnicity and gender in
order to monitor and evaluate the provision of equal employment opportunity and non-discriminatory
employment practices within the state civil service. Complete the form promptly and return it to your
department's Personnel Office with your other hiring documents.
Note: If you choose not to identify, the department is required to visually identify under federal law.
Department
Employee's Name
Last 4 digits of SSN
Person ID Number (if applicable)
GENDER:
Male
Female
RACE AND ETHNICITY
Please check one box that best describes your race or ethnicity.
ASIAN
PACIFIC ISLANDER
BLACK or
AFRICAN AMERICAN (F)
Multiple Pacific
Multiple Asian
(S)
2
Islander
(T)
3
Cambodian (U)
AMERICAN INDIAN or
ALASKA NATIVE (H)
Guamanian (R)
Chinese (J)
Filipino (G)
Hawaiian (P)
HISPANIC or LATINO (alone or
Indian (M)
Samoan (Q)
in combination with any other race)
(D)
Japanese (I)
Other Pacific
Korean (K)
Islander (T)
WHITE (E)
Laotian (V)
MULTIPLE RACES
(Non Hispanic
Vietnamese (L)
1
or Latino) (X)
Other Asian (S)
I choose not to identify. I understand that I must be visually identified under Federal law.
If you identify with more than one race that is non Hispanic or Latino, select Multiple Races.
1
If you identify with more than one Asian ethnicity, select Multiple Asian.
2
If you identify with more than one Pacific Islander ethnicity, select Multiple Pacific Islander.
3
Employee Signature
Date
Privacy Notice on Information Collection
The California Department of Human Resources (CalHR) is committed to maintaining the privacy
of your personal information. All information we collect is governed by the State of California
Information Practices Act of 1977 (Civ. Code, §§ 1798-1798.78), Government Code section
11015.5, Government Code section 11019.9, and the California Public Records Act (Gov. Code,
§§ 6250-6270.5).
CalHR 1070
Page 1 of 2
(rev 1/2017)
State Employee Race/Ethnicity Questionnaire
California Department of Human Resources
State of California
INSTRUCTIONS:
All new/rehired employees are requested to voluntarily self-identify their race/ethnicity and gender in
order to monitor and evaluate the provision of equal employment opportunity and non-discriminatory
employment practices within the state civil service. Complete the form promptly and return it to your
department's Personnel Office with your other hiring documents.
Note: If you choose not to identify, the department is required to visually identify under federal law.
Department
Employee's Name
Last 4 digits of SSN
Person ID Number (if applicable)
GENDER:
Male
Female
RACE AND ETHNICITY
Please check one box that best describes your race or ethnicity.
ASIAN
PACIFIC ISLANDER
BLACK or
AFRICAN AMERICAN (F)
Multiple Pacific
Multiple Asian
(S)
2
Islander
(T)
3
Cambodian (U)
AMERICAN INDIAN or
ALASKA NATIVE (H)
Guamanian (R)
Chinese (J)
Filipino (G)
Hawaiian (P)
HISPANIC or LATINO (alone or
Indian (M)
Samoan (Q)
in combination with any other race)
(D)
Japanese (I)
Other Pacific
Korean (K)
Islander (T)
WHITE (E)
Laotian (V)
MULTIPLE RACES
(Non Hispanic
Vietnamese (L)
1
or Latino) (X)
Other Asian (S)
I choose not to identify. I understand that I must be visually identified under Federal law.
If you identify with more than one race that is non Hispanic or Latino, select Multiple Races.
1
If you identify with more than one Asian ethnicity, select Multiple Asian.
2
If you identify with more than one Pacific Islander ethnicity, select Multiple Pacific Islander.
3
Employee Signature
Date
Privacy Notice on Information Collection
The California Department of Human Resources (CalHR) is committed to maintaining the privacy
of your personal information. All information we collect is governed by the State of California
Information Practices Act of 1977 (Civ. Code, §§ 1798-1798.78), Government Code section
11015.5, Government Code section 11019.9, and the California Public Records Act (Gov. Code,
§§ 6250-6270.5).
CalHR 1070
Page 1 of 2
(rev 1/2017)
Legal Authority for Collection and Use of Information
CalHR, Office of Civil Rights, is requesting the information specified on this form pursuant to
Government Code section 19704, subdivision (b).
The information collected will be used for statistical analysis as required under Government Code
sections 19792 subdivisions (h) and (i). In addition, under Public Law 88-352, Title VII of the Civil
Rights Act of 1964, all state and local governments are required to maintain records and submit a
report to the Equal Opportunity Commission. This information is required to comply with The
Office of Management and Budget's (OMB), Revisions to the Standards for Classification of
Federal Data on Race and Ethnicity.
Disclosure and Sharing
CalHR does not, under any circumstance, sell your electronically collected personal information.
Government Code section 11015.5, subdivision (a) (6) prohibits CalHR and all state agencies from
distributing or selling any electronically collected personal information, as defined above, about
users to any third party without the written permission of the user. Any distribution of electronically
collected personal information will be used solely for its intended use.
However, we may share your personal information under the following circumstances:
1. In published statistical reports. No names, Social Security Numbers, or other personal
identifying information will be provided through these statistical reports.
2. You give us written permission and consent.
3. We may release information to a party with a legal authority, such as a subpoena.
If you elect not to provide the information requested, CalHR will not be able to effectively evaluate
the representation of the state civil service workforce.
Department Privacy Policy
For more information on how we care for your personal information, please read our Privacy
Policy. (http://www.calhr.ca.gov/pages/privacy-policy.aspx)
Access to Your Information
The CalHR Privacy Officer is responsible for maintaining collected records. You have a right to
access records containing your personal information we maintain. To request access, contact:
CalHR Privacy Officer
1515 S Street, 400N
Sacramento, CA 95811
916-324-0455
Privacy.Officer@calhr.ca.gov
Department Instructions
If an employee chooses not to identify, visual identification is required by Title 29, Code of Federal
Regulations section 1602.30 to meet Equal Employment Opportunity Commission EEO-4
reporting requirements. Departments may confidentially destroy this form after it has been keyed.
CalHR 1070
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(rev 1/2017)
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