Online Affirmative Action Survey

	AFFIRMATIVE ACTION
	AREA TEAM MANAGEMENT
	BIDS/RFPs/RFQs
	CREDIT UNION
	CUSTOMER SERVICE
	DIVERSEWORKS
	EMPLOYMENT OPPORTUNITIES
	ENVIRONMENTAL COMMITMENT
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	GEOGRAPHIC INFORMATION SYSTEMS
	LOUISVILLE GREEN
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	RATES, RENTALS & CHARGES
	REGULATORY MANAGEMENT SERVICES
	SAFETY PROGRAMS
	STORMWATER - SANITARY
	TREATMENT PLANTS
	WET WEATHER & WATER QUALITY

Online Affirmative Action Survey

To: All Job Applicants

From: Louisville & Jefferson County Metropolitan Sewer District

In an effort to comply with government record keeping requirements, we ask that you complete this form. Completion of the form is voluntary. Failure to complete the form or the answers provided will not be used in determining your eligibility for employment. This information will be kept separate from your employment application and will be kept confidential. We consider all applications without regard to race, religion, sex, sexual orientation, national origin, age, disability or veteran status.

Position Applied For:
Date:
Referral Source
	Employment Service Courier Journal Louisville Defender Newspaper Advertisement Creative Employment Louisville Urban League Vocational Rehabilitation Unsolicited Other
Race
	White (Caucasian) Black or African American Hispanic (White Race Only) Hispanic (All Other Races) Asian Native Hawaiian or Other Pacific Island American Indian or Alaskan Native (must maintain tribal affiliation)
Gender
	Female Male
Handicapped and Veteran's Information
	1) Are you a Vietnam Era Veteran having more than 180 days of active duty, any part of which occurred between August 5, 1964, and May 7, 1975, with a discharge other than dishonorable; or discharged or released for a service-related disability in the above time period? Yes No
	2) Are you a disabled veteran with a 30 percent disability under the Veterans Administration laws? Yes No
	3) Are you a veteran from any other time period other than that which is stated in Question 1, with a discharge other than dishonorable? Yes No

Louisville and Jefferson County Metropolitan Sewer District
DIVERSEWORKS DEPARTMENT
700 West Liberty Street Louisville, Kentucky 40203-1911 502-540-6282

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Last Updated: July 06, 2005