(1) American Indian or Alaskan Native
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
(3) Black or African American
A person having origins in any of the black racial groups of Africa.
(4) Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
(5) I choose not to self identify
(6) Native Hawaiian or Other Pacific Islander
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
(7) Two or More Races
All persons who identify with more than one of the above five races.
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Vietnam Veteran - (a) A person who served more than 180 days of active military, navy, or air service,
any part of which was during the period of August 5, 1964 through May 7, 1975, and who (1) was discharged or released with other than a dishonorable discharge,
or (2) was discharged or released from active duty because of a service-connected disability if any part of his or her active duty was between August 5, 1964 and May 7, 1975.
(b) A person who served more than 180 days of active military, navy, or air service, who served within the Republic of Vietnam, any part of which was during the period of February 28, 1961
through May 7, 1975, and who (1) was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty because of a service-
connected disability if any part of his or her active duty was between February 28, 1961 and May 7, 1975.
Other Protected Veteran - A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
Special Disabled Veteran - A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (1) rated at 30 percent or more, or (2) rated at 10 to 20 percent in the case of a veteran who has been determined under section 3106 of Title 38, U.S.C., to have a serious employment handicap or (B) a person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran - A veteran who served on active duty in the US military, ground, naval, or air service during a one-year period beginning on the date of a veteransí discharge or release from active duty.
If recently seperated vet, please provide discharge date:
Voluntary Self-Identification of Disability
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:
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Missing limbs or partially missing limbs
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
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Laborís Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
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.
OMB Control Number 1250-0005