Voluntary Self-Identification of Disability Form

  • 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

    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 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 US 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 five minutes to complete.

    OMB Control Number 1250-0005

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P.O. Box 98, Schuylerville, NY 12871 | 518.695.5000 | Fax: 518.695.4970