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Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Page 1 of 1

Expires 04/30/2026


 
Format: MM/DD/YYYY

(if applicable) 

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, 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?

A disability is a condition that substantially limits one or more of your "major life activities." If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson's disease, multiple sclerosis (MS)
  • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
  • Partial or complete paralysis (any cause)
  • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
  • Short stature (dwarfism)
  • Traumatic brain injury
 

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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