Fillable Form 1: VOLUNTARY SELF-IDENTIFICATION OF DISABILITIY (City University of New York)

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Form 1: VOLUNTARY SELF-IDENTIFICATION OF DISABILITIY (City University of New York)

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Rev. 7/14/20 Voluntary Self-Identification of Disability 1
VOLUNTARY SELF-IDENTIFICATION OF DISABILITIY
The City University of New York is subject to certain governmental recordkeeping and reporting requirements for
the administration of civil rights laws and regulations. Submission of this information is voluntary, and refusal to
provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and
may only be used in accordance with the 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
enforcements. When reported, the data will not identify any specific individual.
Because the University does business with the government, we must reach out to, hire and provide equal
opportunities to qualified people with disabilities
1
. 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 CUNY, your response to this self-identification 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 earlier.
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:
• Blindness
• Deafness
• Cancer
• Diabetes
• Epilepsy
• Autism
• Cerebral Palsy
• HIV/AIDS
• Schizophrenia
• Muscular Dystrophy
• Bipolar Disorder
• Major Depression
• Multiple Sclerosis (MS)
• Missing limbs or partially missing limbs
• Post-Traumatic Stress Disorder (PTSD)
• Obsessive-Compulsive Disorder
• Impairments requiring the use of a wheelchair
• Intellectual Disability
1
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal
contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
Rev. 7/14/20 Voluntary Self-Identification of Disability 2
For the below questions, please check all that apply. If you do not wish to disclose the information, please check
the appropriate box.
Are you an individual who has a physical or any other disability?
Yes
No
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of
reasonable accommodation include making a change to the application process or to work procedures, providing
documents in an alternate format, using a sign language interpreter, or using specialized equipment.
If you identify as an individual who has a physical or any other disability, do you require special working
accommodations?
Yes
No
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Completed 2 February 2022

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