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Personal Information

 
 
 
 
 

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Additional Information

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Page 1 of 1

Expires 05/31/2023


 
Format: MM/DD/YYYY

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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:

• Autism• Deaf or hard of hearing• Missing limbs or partially missing limbs
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS• Depression or anxiety• Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
• Blind or low vision• Diabetes• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
• Cancer• Epilepsy
• Cardiovascular or heart disease• Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
• Celiac disease• Intellectual disability
• Cerebral palsy
 

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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.

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Job Title: _______________

Date of Hire: _______________


Employment History:

Responsibilities and Duties


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Voluntary Equal Opportunity Questionnaire

As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.

 
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