Voluntary Self-Identification of Disability
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OMB Control Number 1250-0005
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people
with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals
with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.
Because a person may become disabled at any time, we ask all of our employees to update their information at least
every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer
will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel
decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in
the past. For more information about this form or the equal employment obligations of federal contractors under Section
503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs
(OFCCP) website at www.dol.gov/ofccp
How do you know if you 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:
Autoimmune disorder, for example,
lupus, fibromyalgia, rheumatoid
arthritis, or HIV/AIDS
Blind or low vision
Cardiovascular or heart disease
Deaf or hard of hearing
Depression or anxiety
Gastrointestinal disorders, for
example, Crohn's Disease, or
irritable bowel syndrome
Missing limbs or partially missing
Nervous system condition for
example, migraine headaches,
Parkinson’s disease, or Multiple
• Psychiatric condition, for example,
bipolar disorder, schizophrenia,
PTSD, or major depression
Please check one of the boxes below:
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
I Don’t Wish To Answer
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.
For Employer Use Only
Employers may modify this section of the form as needed for recordkeeping purposes.
Job Title: _______________ Date of Hire: _______________