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Additional Information
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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.

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Page 1 of 1

Expires 04/30/2026


 
Format: MM/DD/YYYY

(if applicable) 

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, 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?

A disability is a condition that substantially limits one or more of your "major life activities." If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson's disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury
 

Please Select one of the options below :

   

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.

For example:

Job Title: _______________

Date of Hire: _______________

Personal Information
What days and hours are you available to work?  
If applying for temporary work, during what period are you available?
     
Are you available to work on weekends?  
Are you available to work overtime, if necessary?  
If hired, on what date can you start work?    
Have you ever applied for work at MedImpact before?
   
Have you ever worked for MedImpact before?
   
Do you have any relatives working for MedImpact?
 
If hired, would you have reliable means of transportation to and from work?  
Are you at least 18 years old?  
(If under 18, hire is subject to verification that you are of minimum legal age and receipt of a valid work permit, when applicable.)
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?  
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
 
[Note: MedImpact complies with the Americans with Disabilities Act and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.]

Have you ever been convicted of a criminal offense (felony or misdemeanor)?
(Convictions for marijuana-related offenses that are more than two years old need not be listed.)

[Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for may, however, be considered.]
 

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