VoluntarySelf-IdentificationofDisability
FormCC-305OMB Control Number1250-0005
Expires1/31/2020
Page1of 2
Becausewe do business with thegovernment,wemustreachout to,hire,andprovide equalopportunitytoqualifiedpeople withdisabilities.i Tohelp usmeasurehowwellwe are doing,we areaskingyou totell usifyouhavea disability orifyoueverhad a disability. Completingthisformisvoluntary,butwe hopethatyouwillchoose tofillit out. Ifyou areapplying forajob, anyansweryougivewillbekept privateand willnotbeusedagainst youin any way.
Ifyoualreadyworkfor us,youranswerwillnotbeusedagainstyouinanyway. Because a person maybecomedisabledat anytime,we arerequiredtoaskallofour employeestoupdatetheir informationevery fiveyears. Youmayvoluntarily self-identifyashaving a disabilityon thisform without fear ofany punishmentbecauseyoudid not identifyas havingadisabilityearlier.
You areconsideredto havea disabilityifyouhave a physical or mental impairmentormedical conditionthatsubstantiallylimitsa majorlifeactivity,orifyouhavea history or record ofsuchan impairmentor medicalcondition.
Disabilitiesinclude,butarenotlimitedto:
- Blindness
- Autism
- Bipolardisorder
- Post-traumatic stressdisorder (PTSD)
- Deafness
- Cerebralpalsy
- Majordepression
- Obsessivecompulsivedisorder
- Cancer
- HIV/AIDS
- Multiplesclerosis(MS)
- Impairmentsrequiringthe use ofawheelchair
- Diabetes
- Epilepsy
- Schizophrenia
- Musculardystrophy
- Missinglimbsor
- Intellectualdisability(previouslycalledmental
Pleasecheckone oftheboxesbelow:
☐ / YES,I HAVE A DISABILITY(orpreviously had adisability)☐ / NO, IDON’THAVE A DISABILITY
☐ / IDON’TWISHTO ANSWER
Your NameToday’sDate
VoluntarySelf-IdentificationofDisability
FormCC-305OMB Control Number1250-0005
Expires1/31/2020
Page2of 2
Federal lawrequires employersto providereasonableaccommodationtoqualified individualswithdisabilities.Pleasetellusifyourequire areasonableaccommodationtoapplyforajobortoperformyour job.Examplesofreasonableaccommodationincludemaking achangetotheapplication processorworkprocedures,providingdocumentsinanalternateformat, usinga signlanguageinterpreter,or usingspecializedequipment.
iSection 503 oftheRehabilitation Actof1973,as amended. Formoreinformationabout thisformortheequalemploymentobligations ofFederal contractors,visitthe U.S.DepartmentofLabor’sOffice ofFederal ContractCompliancePrograms(OFCCP)websiteat
PUBLICBURDENSTATEMENT:According tothePaperworkReductionActof1995no personsarerequiredtorespondto acollection ofinformationunlesssuchcollectiondisplaysa validOMBcontrol number. Thissurveyshould take about 5minutestocomplete.