Gateway Pediatric Therapy
luntary Self-Identification of Disability
OMB Control Number 1250-0005
Page 1 of 2
Why are you being asked to complete this form?
cause we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
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?
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
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
Your Name Today’s Date
• Post-traumatic stress disorder (PTSD)
• Obsessive compulsive disorder
• Multiple sclerosis (MS)
• Impairments requiring the use of a wheelchair
• Missing limbs or
partially missing limbs
• Intellectual disability (previously called mental