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
partiallymissinglimbs /
  • Intellectualdisability(previouslycalledmental
retardation)

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.