OMB Control Number 1250-0005
Page 1 of 2
Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people
. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever
had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job,
any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at
any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-
identify as having a disability on this form without fear of any punishment because you did not identify as having a disability
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits
a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
l Blindness l Autism l Bipolar disorder l Post-traumatic stress disorder (PTSD)
l Deafness l Cerebral palsy l Major depression l Obsessive compulsive disorder
l Cancer l HIVAIDS l Multiple sclerosis (MS) l Impairments requiring the use of a wheelchair
l Missing limbs or
partially missing limbs
l Intellectual disability (previously called mental
YES, I HAVE A DISABILITY (or a previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
Your Name Today's Date
Please check one of the boxes below: