Voluntary Self-Identification of Disability

Completion of this form is for benefited employees only. If any employee, benefited or non-benefited, has a need for reasonable accommodations please contact the Office of Disability Support Services (DSS).

For information regarding the University’s Policy Against Sexual and Other Unlawful Harassment please see policy 4-29

Basic Information Last Name:

First Name:

UDID# (if available):

*Email:

Form

Form CC-305
OMB Control Number 1250-0005
Expires _______

Why are you being asked to complete this form?

Because we do business with the goverment, we must reach out to, hire, and provide equal opportunity to qualified people who have disabilities.i  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 do 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 againt you in any way.        

If you already work for us, your answer will not be used againt you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to udate 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
  • Autism
  • Bipolar disorder
  • Post-traumatic stress disorder (PTSD)
  • Deafness
  • Cerebral Palsy
  • Major depression
  • obsessive compulsive disorder
  • Cancer
  • HIV/AIDS
  • Multiple sclerosis (MS)
  • Impairements requiring the use of a wheelchair
  • Diabetes
  • Schizophrenia
  • Missing Limbs or
    partially missing limbs
  • Intellectual disability (previously called mental retardation)
  • Epilepsy
  • Muscular
    dystrophy
 Please choose one of the options below:

YES, I HAVE A DISABILITY (or have previously had a disability)
 NO, I DON’T HAVE A DISABILITY
 I DON’T WISH TO ANSWER

* Your Name * Today’s Date (mm/dd/yyyy)


Reasonable Accommodation

Federal law requires us to provide reasonable accommodation to qualified individuals with disabilities to ensure equal employment opportunity for all.  If, because of your disability, you require a reasonable accommodation such as a change to application or work procedures, documents in an alternate format, sign language interpreter, or specialized equipment, please let us know.

                                                         

* 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 Labor’s 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.