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Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Page 1 of 1

Expires 05/31/2023


 
Format: MM/DD/YYYY

(if applicable) 

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.


How do you know if you 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:

• Autism• Deaf or hard of hearing• Missing limbs or partially missing limbs
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS• Depression or anxiety• Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
• Blind or low vision• Diabetes• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
• Cancer• Epilepsy
• Cardiovascular or heart disease• Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
• Celiac disease• Intellectual disability
• Cerebral palsy
 

Please Select one of the options below :

   

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.

For Employer Use Only

Employers may modify this section of the form as needed for recordkeeping purposes.

For example:

Job Title: _______________

Date of Hire: _______________


Security Clearance Questionnaire

The intent of this security form is to obtain knowledge of your background.  This questionnaire will help us to determine the extent to which you meet the basic eligibility requirements for obtaining a government issued security clearance.  Responding to the questions on this form is entirely VOLUNTARY.  However, failure to answer will result in not being considered for a position.  Your personal information is protected from unauthorized or accidental disclosure and is only seen by those persons involved in the background investigation, security clearance, and/or hiring process.

Do you currently possess a security clearance?

Have you ever been processed for a Public Trust position?

If yes, issuing agency and date acquired below:

Have you ever had a security clearance or Public Trust Position denied, suspended, or revoked?

If yes, state why below:

Have you ever had Allegiance ties outside the United States?

If Yes, explain below.

Have you ever had Foreign Influences that we should be aware of?

If  Yes, explain below:

Have you ever had Foreign preferences outside the US, such as possession of a valid foreign passport?

If Yes, explain below:

Have you ever been convicted of a Sexual Offense?

If Yes, explain below:

Have you ever had issues with Personal Conduct?

If Yes, explain below:

Have you ever had Financial Considerations, such as judgments, bankruptcy?

If Yes, explain below:

Have you ever had problems with or ever been treated for Alcohol Consumption?

If  Yes, explain below:

Have you ever had issues involving Improper or Illegal Drug Activity?

If  Yes, explain below:

Have you ever had issues regarding Emotional, Mental, and/or Personality disorders?

If  Yes, explain below:

Have you ever had any Criminal Conduct that resulted in a felony, misdemeanors, or imprisonment?

If Yes, explain below:

Have you ever had any Security Violations at previous job?

If Yes, explain below:

Have you ever had any participation in "Outside Activities", such as service/employment with a foreign country?

If Yes, explain below:

Have you ever had any history for misuse of Information Technology Systems?

If Yes, explain below:

Have you ever been terminated from a job/contract for misconduct, poor performance, undesirable allegations, etc.?

If Yes, explain below:

Is there any reason to believe you would not be able to obtain a position of Public Trust and/or government issued Security Clearance?

If Yes, explain below:

I hereby certify that all entries on this attachment are true and complete to the best of my knowledge.  I  understand that all information on this form is subject to verification.

Technatomy Corporation is a Certified Service Disabled Veteran Owned Small Business and an equal opportunity employer.

 


 
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