Psychiatric Gov

Voluntary Self-Identification of Disability

Form CC-305

Page 1 of 1

OMB Control Number 1250-0005

Expires 05/31/2023

Name: Date:

Employee ID:

(if applicable)

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

• Autoimmune disorder, for example,

lupus, fibromyalgia, rheumatoid

arthritis, or HIV/AIDS

• Blind or low vision

• Cancer

• Cardiovascular or heart disease

• Celiac disease

• Cerebral palsy

• Deaf or hard of hearing

• Depression or anxiety

• Diabetes

• Epilepsy

• Gastrointestinal disorders, for

example, Crohn's Disease, or

irritable bowel syndrome

• Intellectual disability

• Missing limbs or partially missing

limbs

• Nervous system condition for

example, migraine headaches,

Parkinson’s disease, or Multiple

sclerosis (MS)

• Psychiatric condition, for example,

bipolar disorder, schizophrenia,

PTSD, or major depression

Please check one of the boxes below:

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability

I Don’t Wish To Answer

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:

Contact this candidate