Fillable Sf256 SF 256 (U.S. Office of Personnel Management)

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Sf256 SF 256 (U.S. Office of Personnel Management)

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SELF-IDENTIFICATION OF DISABILITY
(Please read the Privacy Act information and additional instructions on Page 2)
U.S. Office of Personnel Management
SF 256
Revised October 2016
Previous editions not usable
Name (Last, First, Middle Initial)
Date of Birth (MM/YYYY)
Social Security Number
Purpose:
Each agency in the Executive Branch of the Federal government has established programs to
facilitate the hiring,
placement, and advancement of individuals with disabilities. Self-identification of disability status is essential for effective
data collection and analysis of the Federal government’s efforts. While self-identification is voluntary, your cooperation in
providing accurate information is critical to these efforts.
Every precaution is taken to ensure that the information
provided by each employee is kept in the strictest confidence.
ENTER CODE HERE
Targeted Disabilities or Serious Health
Conditions:
02- Developmental Disability, for example, autism
spectrum disorder
03- Traumatic Brain Injury
19- Deaf or serious difficulty hearing, benefiting from,
for example, American Sign Language, CART,
hearing aids, a cochlear implant and/or other
supports
20- Blind or serious difficulty seeing even when wearing
glasses
31- Missing extremities (arm, leg, hand and/or foot)
40- Significant mobility impairment, benefiting from the
utilization of a wheelchair, scooter, walker, leg
brace(s) and/or other supports
60- Partial or complete paralysis (any cause)
82- Epilepsy or other seizure disorders
90- Intellectual disability
91- Significant Psychiatric Disorder, for example, bipolar
disorder, schizophrenia, PTSD, or major depression
92- Dwarfism
93- Significant disfigurement, for example,
disfigurements caused by burns, wounds, accidents,
or congenital disorders
Other Disabilities or Serious Health Conditions:
13- Speech impairment
41- Spinal abnormalities, for example, spina bifida or scoliosis
44- Non-paralytic orthopedic impairments, for example,
chronic pain, stiffness, weakness in bones or joints, some
loss of ability to use part or parts of the body
51- HIV Positive/AIDS
52- Morbid obesity
59- Nervous system disorder for example, migraine
headaches, Parkinson’s disease, or multiple sclerosis
80- Cardiovascular or heart disease
81- Depression, anxiety disorder, or other psychiatric disorder
83- Blood diseases, for example, sickle cell anemia,
hemophilia
84- Diabetes
85- Orthopedic impairments or osteo-arthritis
86- Pulmonary or respiratory conditions, for example,
tuberculosis, asthma, emphysema
87- Kidney dysfunction
88- Cancer (present or past history)
94- Learning disability or attention deficit/hyperactivity
disorder (ADD/ADHD)
95- Gastrointestinal disorders, for example, Crohn's Disease,
irritable bowel syndrome, colitis, celiac disease, dysphexia
96- Autoimmune disorder, for example, lupus, fibromyalgia,
rheumatoid arthritis
97- Liver disease, for example, hepatitis or cirrhosis
98- History of alcoholism or history of drug addiction (but not
currently using illegal drugs)
99- Endocrine disorder, for example, thyroid dysfunction
Other Options:
01- I do not wish to identify my disability or serious
health condition.
05- I do not have a disability or serious health condition.
06- I have a disability or serious health condition, but it
is not listed on this form.
Page 1 of 2
U.S. Office of Personnel Management
SF 256
Revised October 2016
Previous editions not usable
Definition
An individual with a disability: A person who (1) has a physical or mental impairment which substantially limits one or
more major life activities; (2) has a record of such an impairment; or (3) is regarded as having such an impairment. This
definition is provided by the Rehabilitation Act of 1973, as amended (29 U.S.C. 701, et seq.).
The Rehabilitation Act of 1973
The Rehabilitation Act of 1973, as amended (29 U.S.C. 701, et seq.), requires each agency in the Executive Branch of the
Federal government to establish programs that will facilitate the hiring, placement, and advancement of individuals with
disabilities. One method for determining agency progress in fulfilling these requirements is through the production of
reports at certain intervals showing, for example, the number of employees with disabilities who are hired, promoted,
trained, or reassigned over a given time period; the percentage of employees with disabilities in the work force and in
various grades and occupations; etc. Such reports bring to the attention of agency top management, OPM, and the
Congress, the progress or any deficiencies within specific agencies or the Federal government as a whole in the hiring,
placement, and advancement of individuals with disabilities.
The disability data collected on employees will be used only in the production of reports such as those previously
mentioned and not for any purpose that will affect them individually. The only exception to this rule is that the records
may be used for selective placement purposes and selecting special populations for mailing of voluntary personnel
research surveys. In addition, every precaution will be taken to ensure that the information provided by each employee is
kept in the strictest confidence and is known only to those individuals in the agency Personnel Office, who obtain and
record the information for entry into the agency’s and OPM’s personnel systems. You should also be aware that
participation in the disability reporting system is entirely voluntary, with the exception of employees appointed under the
Schedule A Excepted Appointing Authority for People with Intellectual Disability, Severe Physical Disability, or Psychiatric
Disability (5 CFR 213.3102(u)). Agencies will request that these employees identify their disability status and, if they
decline to do so, their correct disability code will be obtained from medical documentation used to support their
appointment.
Employees who wish to confirm the disability code carried in their agency’s and OPM’s personnel systems is consistent
with the employees’ representation, may ask their Personnel Officer for a printout of the code and definition from their
individual records. The code noted in the employees’ records in the agencies’ system will be identical to that carried in
OPM’s system.
Privacy Act Statement
Collection of the requested information is authorized by the Rehabilitation Act of 1973, as amended (29 U.S.C. 701, et
seq.). Solicitation of your Social Security Number (SSN) is authorized by Executive Order 9397, which permits agencies to
use the SSN as a means for identifying persons with disabilities in personnel information systems. Your SSN will only be
used to ensure that your correct disability code is recorded along with other employee information that your agency and
OPM maintain on you. It should be noted, however, that where individuals decline to furnish their SSN, the SSN will be
obtained from other records in order to ensure accurate and complete data. Employees appointed under the Schedule A
Appointing Authority for People with Intellectual Disability, Severe Physical Disability, or Psychiatric Disability (5 CFR
213.3102(u)) are requested to furnish an accurate disability code, but failure to do so will not affect them. Where
employees hired under this authority fail to disclose their disability, the appropriate code will be determined from the
employee’s existing records or medical documentation submitted upon appointment.
Page 2 of 2
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Completed 24 July 2020

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