Invitation to Self-Identify as a Veteran
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: (1) disabled veterans; (2) recently
separated veterans; (3) active duty wartime or campaign badge veterans; and (4) 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 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
a United States military operation for which an Armed Forces service medal
was awarded pursuant to Executive Order 12985.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by
checking the appropriate box below.
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.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
I AM NOT A PROTECTED VETERAN
I DON'T WISH TO ANSWER
OMB Control Number 1250-0005
Voluntary Self-Identification of Disability
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. 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.
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:
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.
iSection 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.