Texas Government Code Section 552.024 Public Access Option Form by nsr11162


									                                                   PERSONAL DATA INFORMATION &
                                               TEXAS GOVERNMENT CODE SECTION 552.024 /
                                                     PUBLIC ACCESS OPTION FORM

Section I:
Gender:         [ ] Female [ ] Male               Date of Birth: ___________________
Racial Ethnic Group:
[ ] White (Non-Hispanic)           [ ] Black or African American     [ ] Two or more races
[ ] Hispanic or Latino             [ ] Asian                         [ ] Other:________________
[ ] American Indian/Alaskan Native [ ] Native Hawaiian/Pacific Islander
Section II:
If you are a veteran of the Vietnam Era, or have other military status we would appreciate your assistance
in telling us the following information by checking the appropriate items that may apply to you.

[ ] I choose not to disclose / Not applicable
[ ] Qualified Disabled Veteran: Any person entitled to compensation by the Veterans Administration
    for a disability rated at 30 percent or more, or a person who was discharged or released from
    Active Duty by reason of a service connected disability.
[ ] Veteran of the Vietnam Era: Any veteran of the armed services who served on active duty for at
    least 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was
    discharged honorably or released sooner because of a service related disability.
[ ] Reservist or member of the National Guard
[ ] Other:_______________________________________________________________
“The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights
laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or
ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. This
information obtained will be kept confidential and may only be used in accordance with provisions of applicable laws, executive
orders, and regulations, including those that require the information to be summarized and reported to the federal government for
civil rights enforcement. When reported, data will not identify any specific individual.”

      Texas Government Code Section 552.024 / Public Access Option Form
The Public Information Act allows employees, public officials and former employees and officials to
elect whether to keep certain information about them confidential. Unless you choose to keep it
confidential, the following information about you may be subject to public release if requested under the
Texas Public Information Act. Therefore, please indicate whether you wish to allow public release of the
following information.

                                                                                                                Public Access?
                                                                                                                   No      Yes
Home Address
Home Telephone Number
Social Security Number
Information that reveals whether you have family members

______________________________________                               _______________________________________
Signature                                                            Name (print)
______________________________________                              ________________________________________
Date                                                                SSN#

                                                                                                                      April 18, 2007

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