OMB Control Number 1250-0005
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
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
Disabilities include, but are not limited to: Blindness, Deafness, Cancer,
Diabetes, Epilepsy, Autism, Cerebral palsy, HIV/AIDS, Schizophrenia, Muscular
dystrophy, Bipolar disorder, Major depression, Multiple sclerosis (MS), Missing
limbs or partially missing limbs, Post-traumatic stress disorder (PTSD),
Obsessive compulsive disorder, Impairments requiring the use of a wheelchair,
Intellectual disability (previously called mental retardation).
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 Labors 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.