VOLUNTARY SELF – IDENTIFICATION OF DISABILITY
Why are you being asked to complete this form?
Because we do business w
ith 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 or 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.
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 impairment or medical condition.
Examples of disabilities include, but are not limited to:
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder (OCD)
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Missing limbs or partially
Intellectual disability (previously called mental
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
VOLUNTARY SELF – IDENTIFICATION OF VETERAN STATUS
Veteran status is defined as follows by the U.S. Department of Veterans Affairs. Please check all that apply.
Armed Forces Serv
ice Medal Veteran - a veteran who, while serving on active duty in the U.S. military, ground,
naval or air service, participated in a United States military operatio
n for which an Armed Forces service medal was
awarded pursuant to Executive Order 12983 (61 Fed. Reg. 1209).
Disabled Veteran - (i) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or
who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the
Secretary of Veterans Affairs, or (ii) a person who was discharged or released from active duty because of a service-
Recently Separated Veteran - a veteran during the three-year period beginning on the date of such veteran’s
release from active duty in the U.S. military, ground, naval or air service.
Other Protected Veteran – a veteran who
served on active duty in the U.S. military, ground, naval or air service
during a war, or in a campaign or expedition for which a campaign badge has been authorized. Information required to
make this determination is available at:
http://www.opm.gov/veterans/html/vgmedal2.htm or by calling (301) 306 6752
and requesting that a copy of the list be mailed to you.
Active Duty Wartime Campaign Badge Veteran – An “active duty wartime or campaign badge veteran” means a
veteran who served on active duty in the U.S. military, ground, naval or air
service during a war, or in a campaign or
expedition for which
a campaign badge has been authorized under the laws administered by the Department of
am a protected veteran, but choose not to self-identify the classification to which I belong.
I don’t wish to answer.
I am not a protected veteran.