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Why are you being asked to complete this form?

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Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. ⁱ 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.

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How do I know if I have a disability?

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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)

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Reasonable Accommodation Notice

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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.

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ⁱ 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 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 5 minutes to complete.

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[Goodwill Industries of North Florida (Goodwill)] is a Federal contractor and an Equal Opportunity Employer. Goodwill is subject to Executive Order 11246, which requires government contractors to take affirmative action to ensure that equal opportunity is provided in all aspects of their employment. In addition, we are subject to Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment protected veterans. In order to comply with these laws, Goodwill invites applicants to voluntarily self-identify their gender, race/ethnicity and protected veteran status. Goodwill does not discriminate on the basis of race, religion, color, sex, sexual orientation, gender identity, age, protected veteran status, non-disqualifying physical or mental disability, national origin, genetic information, or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

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Select one of the following:

Select Male Female I choose not to self-identify

Select one of the following race/ethnic groups defined on the following page:

Select one of the following:

I identify as one or more of the classifications of protected veterans as defined on the following page

Personal and Confidential This page contains sensitive information, store in secure "Affirmative Action Forms" files, separately from personnel records.

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.

Ethnicity and Race Definitions

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• Hispanic or Latino

  - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

• White (Not Hispanic or Latino)

  - A person having origins in any of the original peoples of Europe, theMiddle East, or North Africa.

• Black or African American (Not Hispanic or Latino)

  - A person having origins in any of the blackracial groups of Africa.

• Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

  - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• Asian (Not Hispanic or Latino)

  - A person having origins in any of the original peoples of the FarEast, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• American Indian or Alaska Native (Not Hispanic or Latino)

  - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

• Two or More Races (Not Hispanic or Latino)

  – A person who identifies with more than one of the above five races.

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Protected Veteran Definitions

• Disabled Veteran - one of the following:

  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
  - a person who was discharged or released from active duty because of a service-connected disability.

• Recently Separated Veteran

  - any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

• Active Duty Wartime or Campaign Badge 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 under the laws administered by the Department of Defense.

• Armed forces service 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 operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

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I,   , confirm that I am available for temporary assignments which may be offered to me in accordance with condition applicable to Goodwill Staffing Services, as set out below.

1. Wages will be paid only for those hours which are actually worked, lunch hours excluded. Goodwill Staffing Services pays its employees once a week. Our pay period starts on Sunday and ends on Saturday. Payday is every Friday from 8:00 a.m. to 3:00 p.m. All checks that are not picked up on Fridays will be mailed via the US Postal Service. If you cash your check before the date on the check issued to you there will be a $50 early cashing penalty fee.

If a check is lost or stolen it must be reported immediately. Checks will be reissued two (2) weeks after the stop payment has been placed on the check unless it has been cashed prior to the stop payment. I understand in order to be paid in a timely matter; time cards must be turned in no later than 9:00 A.M. each Monday following the week worked. Any late time cards will not be paid until the next payroll period which is the following week.

2. I understand I am an employee of Goodwill Staffing Services, and I represent Goodwill Staffing Services when sent out on a temporary assignment. I understand that I am expected to complete any job assignment that I accept. Should an offer of employment be made by a Client/Company/Employer while the employee is on an assignment of Goodwill Staffing Services, the employee is free to accept such an offer, however, the employee is required to advise Goodwill Staffing Services of such an offer and acceptance.

3. If for some unexpected reason, such as an emergency or illness, I can not make it to work or will be late, I will contact Goodwill Staffing Services at least one hour prior to my scheduled shift so Goodwill Staffing Services can call the Client/Company/Employer and/or find a replacement. All absences 3 days and over must be supported with documentation (i.e. from a doctor).

4. If I sustain an injury on the job, I will inform the Client/Company/Employer and Goodwill Staffing Services immediately after the accident. Goodwill Staffing Services will coordinate with the client and myself, the proper procedure for treatment and reporting of the accident.

5. Confidentiality of information obtained on an assignment is paramount. I agree that I will not divulge, to any person, information obtained on as assignment that may represent a breach of trust, security, or trade secret that would be injurious to the client of Goodwill Staffing Services.

6. I understand that Goodwill Staffing Services has a Drug & Alcohol Policy. I understand that a pre-placement drug test will be conducted for applicants under consideration for certain assignments. No drug and/or alcohol test will be conducted without an employee's consent. However refusal to consent will result in disciplinary action up to and including termination.

7. There may be assignments offered from time to time which may require passing a physical examination. I am free to reject such examination and in such a case that particular assignment may be held open for me or I may be withdrawn from it. Other assignments may still be offered to me which don't require a physical.

8. I understand that Goodwill Staffing Services requires two weeks notice of my intention to resign. If you plan to voluntarily terminate your employment in good standing, you must provide two weeks notice. Notice of intention to resign must be given in writing to Goodwill Staffing Services.

9. I understand that Goodwill Staffing Services, Goodwill Industries of the Chesapeake, Inc., and Goodwill Works, have established performance standards for all employees. Employees may be terminated for attendance infractions, incompetence, irresponsibility, insubordination, and/or failure to observe rules, policies, and regulations. Please note that these are not the only reasons an employee may be terminated. Fighting, theft, or insubordination are grounds for immediate termination. I also understand that failure to call and advise Goodwill Staffing Services of any absence is considered a no call, no show, which is job abandonment and grounds for immediate termination.

10. I understand that all assignments through Goodwill Staffing Services are temporary work assignments. All job placements are based on an employer's temporary employment needs and therefore can end at any time and for any reason or cause.

PLEASE INITIAL HERE: 

11. I have read and fully understand the above statements regarding Goodwill Staffing Services employee agreement and agree to the same. I understand that failure to comply with this agreement could lead to my termination.

12. I, the undersigned, acknowledge receipt of a copy of this employee agreement to keep.

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PROGRAM PURPOSE AND OBJECTIVES

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The Alcohol and Drug Free Workplace Program of Goodwill Staffing Services was established to maintain a productive, secure, safe, and healthy environment for all employees. Through this program, Goodwill Staffing Services intends to:

• Communicate the risks and dangers associated with casual and long term substance abuse;
• Take all reasonable steps necessary to protect the safety of our employees while maintaining a high level of productivity and quality service;
• Help eliminate substance abuse in our workplace and assist employees to seek help in dealing with abuse problems;
• Reduce the rate of accidents in the workplace.

This program will apply to all applicants for employment and Goodwill Staffing Services employees.

REQUIRED TESTS

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This program provides for the testing of applicants for employment for the use of drugs through a pre-employment drug test as required for certain job assignments.>

Employees will be tested for the use of drugs and/or alcohol under the following conditions:

• Reasonable Suspicion
• Random
• Follow Up Random, if needed.

Employees will be paid for the time needed to comply with testing when required by Goodwill Staffing Services Applicants for employment will not be compensated for the time needed to comply with testing. Urine specimens will be tested for the presence of drugs. Alcohol testing will be performed using an evidential breath testing device. Goodwill Staffing Services reserves the right to require blood alcohol testing for reasonable suspicion and post accident. All drug and alcohol testing will be carried out in compliance with Maryland law. Specimens will be tested by a NIDA certified laboratory.

Any employee who alters or attempts to alter, substitute or contaminate a drug and/or alcohol specimen will be subject to disciplinary action up to and including termination.

REASONABLE SUSPICION

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This program provides for the testing of employees for the use of drugs and/or alcohol when a supervisor has a reasonable suspicion that the employee is unfit for duty or has used or is using chemical substances prohibited under this program. If a supervisor has reason to believe that an employee is impaired, as evidenced by such behaviors or indicators as mood swings, odor of alcohol, slurred speech, poor coordination, bloodshot/glassy eyes, a "Report of Reasonable Suspicion Incident" form must be completed immediately following the observation of suspicious behavior. This report will fully document the supervisor's observations. The report must be completed before an employee can be sent for testing. Specimen collection must be done as soon as possible following the completion of the report. If an employee is requested to submit to a drug and/or alcohol test, a consent form must be completed. An employee's refusal to comply with the testing procedure will be cause for immediate termination. Any employee required to submit to testing will be suspended without pay until the results of the testing are obtained. If the drug test results are negative and/or the breath alcohol test is reported as less than 0.02, the employee will receive pay for scheduled hours not worked while suspended. Goodwill Staffing Services may require documentation from an appropriate professional regarding the employee's condition before allowing the employee to return to work.
If the employee leaves the worksite driving a vehicle, the supervisor may notify the police that he/she has reason to believe the employee may be driving under the influence of drugs and/or alcohol.

FOLLOW-UP TESTING

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An employee who tests positive for drugs and/or alcohol will be required to submit to follow-up testing. Follow-up testing may be required for up to five years after the employee's return to work. A positive result on any follow-up drug and or alcohol test will result in disciplinary action up to, and including, termination.

GENERAL REGULATIONS

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1. The improper manufacture, distribution, dispensation, possession, sale, transfer, purchase or use of chemical substances, including alcohol, on Goodwill Staffing Services property (which includes but is not limited to, Goodwill Staffing Services worksites, parking lots, and vehicles) or during working hours, including rest and meal periods, is considered misconduct and may result in disciplinary action up to and including termination.

2. Employees must notify Goodwill Staffing Services of any criminal drug or alcohol statute conviction within five (5) days of such conviction. Failure to do so may be considered misconduct and result in disciplinary action up to and including termination.

3. No prescription drugs will be brought onto company property by any employee other than the employee for whom it is prescribed. Medications must be carried in the prescription container. The use of prescription drugs will be according to the manner and quantity prescribed. Employees on physician prescribed medicine must notify their supervisor if there is a possibility the medication could affect job performance. Goodwill Staffing Services may refuse to allow the employee to work unless the employee stops taking the medicine: a) until the effects will not be experienced during the employee's working hours; or b) upon presenting a note from the prescribing physician stating there are no adverse side effects from taking the prescription which would impair the employee's ability to perform his/her job safely. Failure to do so will be considered misconduct and may result in disciplinary action up to and including termination.

4. No drug and/or alcohol test will be conducted without an employee's consent. However, refusal to consent will result in disciplinary action up to, and including, termination.

5. A tested employee will be informed of the name and address of the lab upon request, and may request independent testing at the employee's expense. Any employee who tests positive will be provided with a copy of the lab test results, a copy of this written policy, a written notice of disciplinary action, and Test results will be kept confidential and disclosed only on a need-to-know basis.

I, the undersigned, acknowledge receipt of a copy of this alcohol & drug free workplace program to keep.

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I certify that the information I have provided on this application and any attachments thereto, is true and complete to best of my knowledge and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated.

I authorize Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. to investigate my professional background, educational background, qualifications and all other statements made on this application. I release Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. and anyone supplying information to Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. as well as their respective agents, from liability in connection with this investigation.

I understand that, as a condition of employment, I may be asked to disclose information pertaining to felony convictions, within the last seven (7) years. I understand that certain positions, as a condition of employment, require a criminal background investigation permitted under the Fair Credit Reporting Act. If I am applying for a position that requires such an investigation, I understand that any offer of employment made by Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. is expressly conditioned on the findings of the investigation. I understand that if Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. obtains information that leads it to conclude, in its discretion, that I should not be employed, it may rescind any job offer or terminate my employment.

I understand that, as a condition of employment, or at any time during the employment relationship, I may be asked to consent to a drug test. If I refuse to consent or cooperate in the conduct of such a test or if I test positive for a controlled substance, I understand that Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. may rescind any job offer or terminate my employment.

I further understand that if hired by Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. my employment is for no definite period and that either Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. or I may terminate the employment relationship without prior notice or reason. I also understand that none of Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc.'s practices and policies are to be construed as imposing any binding obligation on Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc.'s, and that they are subject to change or deletion at any time.

UNDER MARYLAND LAW, AM EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECTTO A FINE NOT EXCEEDING $100.00.

Goodwill Staffing Services/Goodwill Industries of the Chesapeake, Inc. is an equal opportunity employer dedicated to nondiscrimination in employment on the basis of race, color, religion, age, gender, disability, marital status, sexual orientation, genetic information, national origin, veteran's status or other classification covered by federal, state or local law.

I have read and understand the information outlined in these paragraphs and by providing my signature below I agree with these terms.

I agree with the above statement.

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Goodwill Staffing Services takes your health and safety very seriously. Because it is important that we be able to manage our safety program, there are specific rules you must follow to prevent injuries. If you have an injury on the job you must immediately notify a Goodwill Staffing Services representative before obtaining medical treatment. Failure to follow the basic safety rules and instructions may result in disciplinary action, up to, and including termination.

1. If you have an injury:

• Immediately report your injury to the site supervisor.
• Immediately (within 15 minutes) report your injury to a Goodwill Staffing Services representative, who will advise how to proceed.
• Complete an accident report form available from your Goodwill Staffing Services representative within 24 hours of the incident.
• If medical treatment is necessary, all documentation relating to your treatment, including a release form from your doctor to return to work must be sent to Goodwill Staffing Services.
• If your injury is critical or life-threatening, your site supervisor or Goodwill Staffing Services representative will make sure you receive immediate medical attention.

2. Personal protective equipment (PPE) must be worn when required on specific jobs. You will be provided equipment designed specifically to protect you from injury. Any deficiencies in the required PPE must be immediately reported to your Goodwill Staffing Services representative.

3. Eye protection must be worn if you are exposed to flying objects and dust.

4. Report hazards immediately to a company official who has the authority to see that it is corrected.

5. Wear clothing that fits the job. Sandals, canvas or similar sport shoes are prohibited at production or construction sites, as are loose hair, clothing and jewelry when working around machinery.

6. If you work in a way that might cause an injury to yourself or others you will be warned and disciplinary action may follow, up to and including termination.

7. Do not work in any situation where the work might be considered dangerous. If there is doubt, consult your Goodwill Staffing Services representative.

8. No practical jokes, scuffling or other horseplay in permitted.

9. Do not operate a machine unless guards are in place and the machine is in good working order.

10. Keep your area clean. You are responsible for cleaning up any hazards you create.

11. Obey "no smoking" rules at each job site.

12. Obey all rules regarding use of personal cell phones at each job site.

13. You are strictly forbidden to ride on forklifts and carriers or any mobile equipment as passengers.

14. You must be checked out on trucks, forklifts and production equipment prior to use.

15. Do not walk in the pathway of operating equipment or vehicles, or walk across moving conveyors.

16. Do not use your hands or any portion of your body to reach between hazardous moving parts of a machine for any reason.

17. The use of intoxicating liquor or drugs on the job or reporting to work under the influence of intoxicants is prohibited.

18. No weapons are permitted in the workplace.

19. Get to know where emergency exits, fire extinguishers and safety equipment are located.

I have read and understand these safety rules. I understand I must obey all safety rules, regulations and safe work practices. Failure to obey safety rules and safe work practices, including accident reporting procedures, may be grounds for disciplinary action up to and including termination.

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As an Equal Opportunity employer ,Goodwill Industries of the Chesapeake ,Inc. does not discriminate against qualified applicants based upon race ,color, religion, age, gender, disability ,marital status, sexual orientation , genetic information, national origin ,veteran’s status ,or such classification covered by federal, state or local laws.

We invite you to complete the self-identification fields below used for compliance with government regulations and record keeping guidelines .Completion of these question is voluntary, and this information is not available to hiring managers. Refusal to provide the requested information will not result in adverse treatment .Information provided is not considered part of your application and will be treated confidentially.

Thank you for your help and cooperation.

Gender:	Select Male Female I chose not to disclose
Ethnic Group:
Race:

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Name:

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Revised EEO-1 Ethnicity and Race categories Descriptions Hispanic or Latino A person of Cuban, Mexican, Puerto, Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the middle East , or North Africa. Black or African American(Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Asian(Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia , or the Indian subcontinent including , for example ,Cambodia ,China ,India, Japan, Korea , Malaysia, Pakistan, the Philippine Islands , Thailand, and Vietnam. Native Hawaiian or Other Pacific islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii , Guam, Samoa ,or other Pacific Islands. American Indian or Alaskan Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment . Two or more Races (Not Hispanic or Latino) All persons who identify with more than one of above five races.

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Goodwill Industries of the Chesapeake is an equal opportunity corporation and does not discriminate on the bases of race ,color, sex, national origin, religion, age, disability or veteran’s status in admission or access to, or treatment or employment in, its programs and activities. Individuals who may have inquiries regarding the corporation’s policy and procedures should contact Vice President of Human resources at 410-837-1800.

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This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974,as amended by the jobs for Veterans Act of 2002,38 U.S.C. 4212 (VEVRAA),which requires Government contractors to take affirmative action to employ and advance in employment.

• Disabled veterans
• Recently separated veterans
• Active duty wartime or campaign badge veterans
• Armed Forces service medal veterans

These classifications are defined as follows :

• A “disabled veteran” is one of the following :
  
  
  • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of the military retired pay would be entitled to compensation) under laws administered by the secretary of veterans affairs; or
  
  
  • a person who was discharged or released from active duty because of a service-connected disability.
  
  
• A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military ,ground ,naval, or air service.


• 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 Defense.


• An “Armed Forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in the United states military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.


• Protected veterans may have additional rights under USERRA – The Uniformed Services Employment and Reemployment Rights Act. In particular ,if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployment by your employer in the position you would have obtained with Reasonable certainty if not for the absence due to service. For more information, call the U.S. department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by selecting the appropriate choice .As a government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

My Choice Is:*

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Why are you being asked to complete this form?

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Because we do business with 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 has 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 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?

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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 of 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)

My Choice Is:*

Select Yes NO I choose not to self-identify

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Reasonable Accommodation Notice

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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 alternative format , using a sign language interpreter , or using specialized equipment.

ⁱ 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 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 5 minutes to complete.