Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
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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)
Please check one of the boxes below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
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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.
Voluntary Self-Identification Minorities and Women
KML Law Group, P.C. is a government contractor and is subject to Executive Order 11246, as amended and other various reporting requirements. These reporting requirements necessitate that we track and report our applicants and employees by gender and race/ethnicity to the government. This information is also used for the purpose of monitoring the success of our Affirmative Action Program efforts. We are an organization that values diversity and encourages women and minorities to apply. For this reason, we invite you to indicate your gender and race/ethnicity below. This information is kept separate from your application or, if an employee, will be kept in a separate confidential personnel file.
This information will not be used to discriminate against or show preference for any applicant or employee in hiring, promotions or any other personnel action. Submission of this information is strictly voluntary and refusal to provide it will not subject you to discharge, disciplinary treatment, or any form of retaliation.
Position(s) for which you are applying (applicants only):
Definitions of Race/Ethnic Categories
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
American Indian or Alaskan Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
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.
Black or African American (not Hispanic or Latino) - A person having origins in any of the Black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Two or More Races (not Hispanic or Latino) - All persons who identify with more than one of the above five races.
Voluntary Veteran Self-Identification Form: Pre and Post Offer Solicitation
This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended (VEVRAA) which requires Government contractors to take affirmative action to employ and advance in employment:
Recently separated veterans;
Active duty wartime or campaign badge veterans; and
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. Your Form DD-214 may help you make this determination. 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. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be maintained confidentially and used only in ways that are consistent with VEVRAA.
I identify as one or more of the classifications of protected veterans listed above
I am not a protected veteran
I decline to disclose my protected veteran status
If you are disabled veteran, please let us know if there any reasonable accommodations we could make that would enable you to be considered for a job opening or perform the essential functions of the position you hold. We consider requests for accommodation on a case-by-case basis.