Form Cc-305 - Confidential Voluntary Questionnaire (Page 2 of 4) in pdf

Voluntary Self-identification of

Disability

FomCC-305

0MB Control Number 1250-0005

Expfres 1131/2017

Page 1 of 2

Why are you being asked to complete this form?

Because 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?

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:

• Blindness

• Deafness

• Cancer

• Diabetes

• Epilepsy

• Autism

• Cerebral palsy

• HIV/AIDS

• Schizophrenia

• Muscular

dystrophy

• Bipolar disorder

• Major depression

• Multiple sclerosis (MS)

• Missing limbs or

partially missing limbs

• Post-traumatic stress disorder (PTSD)

• Obsessive compulsive disorder

• Impairments requiring the use of a wheelchair

• Intellectual disability (previously called mental

retardation)

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER

Your Name

Today’s Date

Form Cc-305 - Confidential Voluntary Questionnaire Page 2

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