R3 SSG Voluntary Self-Identification of a Disability Form

OMB Control Number 1250-0005, Expires 1/31/2017

R3 SSG is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal state or local laws. R3 SSG IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, R3 SSG OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Though all major browsers can be used to complete this form, we recommend using Google Chrome or Mozilla Firefox. If you experience a problem with the application form using a certain browser, please fill out the application using a different one.

If you have any questions regarding this form, please contact your Human Resources department or your supervisor.


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In order for R3 to review your application, you must complete all four steps of the application process.

After submitting the current form, be directed to Step 4 of 4.

Section 1: General Applicant Information

Why am I 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 provide 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 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.


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.

Type your full name (First Middle Last) into the box.

Step 3 of 4


In order for R3 to review your application, you must complete all four steps of the application process.

After submitting the current form, you will be directed to Step 4 of 4.

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