Employment Application - City Of Newport (Page 6 of 9) in pdf

Employment Application - City Of Newport Page 6

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

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 (MS)

 Impairments requiring the use of a

wheelchair

 Diabetes

 Schizophrenia

 Missing limbs or

 Intellectual disability (previously called mental

 Epilepsy

 Muscular

partially missing limbs

retardation)

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

Employment Application - City Of Newport Page 6

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