Demographic Survey for Cologix

We invite you to complete this optional survey. Submission of the information on this form is strictly voluntary, and declining to provide it will not subject you to any adverse treatment or affect your job application. Information obtained will be kept separate from your name or job application. This information will be kept secure and confidential.

• Gender
  • Female
  • Male
  • Declining to Self-Identify
• Race
  • White (Not Hispanic or Latino)
  • Hispanic or Latino
  • Black or African American (Not Hispanic or Latino)
  • Asian (Not Hispanic or Latino)
  • Native Hawaiian or other Pacific Islander (Not Hispanic or Latino)
  • American Indian or Alaska Native (Not Hispanic or Latino)
  • Two or More Races (Not Hispanic or Latino)
  • Declining to Self-Identify
• Veteran status
  • I am a veteran
  • I am not a veteran
  • Declining to Self-Identify
• Disability

  How do you know if you have a disability? A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to: Alcohol or other substance use disorder (not currently using drugs illegally) Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS Blind or low vision Cancer (past or present) Cardiovascular or heart disease Celiac disease Cerebral palsy Deaf or serious difficulty hearing Diabetes Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders Epilepsy or other seizure disorder Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome Intellectual or developmental disability Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD Missing limbs or partially missing limbs Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS) Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities Partial or complete paralysis (any cause) Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema Short stature (dwarfism) Traumatic brain injury

  • Yes, I have a disability, or have had one in the past
  • No, I don't have a disability and have not had one in the past
  • I do not wish to answer