Form 138 - Employment Application (Page 3 of 4) in pdf

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

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  Autism

 Bipolar disorder

 Post-traumatic stress disorder (PTSD)

 Deafness

 Cerebral palsy

 Major depression

 Obsessive compulsive disorder

 Cancer

 HIV/AIDS

 Multiple sclerosis

 Impairments requiring the use of a

(MS)

wheelchair

 Diabetes

 Schizophrenia

 Missing limbs or

 Intellectual disability (previously called

 Epilepsy

 Muscular

partially missing

mental retardation)

limbs

dystrophy

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 #138 (revised 2/29/2016)

3 of 4

Form 138 - Employment Application Page 3

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