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Disability Self-Identification Form

The document discusses a voluntary disability declaration form. It explains that completing the form will help employers provide reasonable accommodations. It notes that disability includes physical or mental impairments that limit major life activities and provides some examples. It asks individuals to check if they require accommodations or have a disability.

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Amit
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185 views2 pages

Disability Self-Identification Form

The document discusses a voluntary disability declaration form. It explains that completing the form will help employers provide reasonable accommodations. It notes that disability includes physical or mental impairments that limit major life activities and provides some examples. It asks individuals to check if they require accommodations or have a disability.

Uploaded by

Amit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Disability Declaration

** Mandatory fields are marked with a red indicator.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

It is the responsibility of the employee to inform the employer that an accommodation is needed. Having this
information will help employer to provide you with assistance of reasonable accommodation to a position or
workplace that will enable you to do job despite having 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 Autism Bipolar disorder Post-traumatic stress disorder (PTSD)


Deafness Cerebral palsy Major depression Obsessive compulsive disorder
Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair
Diabetes Schizophrenia Missing limbs or partially missing limbs Intellectual disability(previously called mental retardation)
Epilepsy Muscular dystrophy

** Please check one of the options below:

Your Name *Today's Date


Neha Mishra 21 Sep 2023

IP Address:

122.161.67.240, 96.17.182.204, 23.41.167.185, 23.62.100.160|10.70.1.87


Disability Declaration

Reasonable Accommodation Notice

Employers are required 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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