Fillable Form CC-305: Vo luntary Self-Identification of Disability cause

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Form CC-305: Vo luntary Self-Identification of Disability cause

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Gateway Pediatric Therapy
Vo
luntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Be
cause we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
i
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 earlier.
How do I know if I have a disability?
Yo
u 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:
Please check one of the boxes below:
☐
YES, I HAVE A DISABILITY (or previously had a disability)
☐
NO, I DON’T HAVE A DISABILITY
☐
I DON’T WISH TO ANSWER
__________________________ __________________
Your Name Today’s Date
• Blindness
• Autism
• Post-traumatic stress disorder (PTSD)
• Deafness
• Cerebral palsy
• Obsessive compulsive disorder
• Cancer
• HIV/AIDS
• Impairments requiring the use of a wheelchair
• Diabetes
• Epilepsy
• Schizophrenia
• Muscular
dystrophy
• Intellectual disability (previously called mental
retardation)
Gateway Pediatric Therapy
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
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 work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i
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.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
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Form CC-305: Vo luntary Self-Identification of Disability cause

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Completed 26 October 2020

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