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Personal Information

 
 
 
 
 

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If you selected "Employee Referral" in the source box above please list our employees name in the "Referred By" box.

 


Additional Information

Do you have any relatives currently employed at FedData?  Yes/No

 

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If Yes, please know that FedData HR will be reaching out to you for additional information.

 

What is your current Clearance Level?

Are you subject to the terms of an employment agreement, including any non solicitation or non compete restrictions? 

If answer is YES, please provide details.

If answer is NO, please write N/A.

Are you subject to the terms of any organizational or personal conflict of interest agreement?

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If answer is NO, please write N/A.

Are you subject to any restrictions stemming from prior Government service? 

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If answer is NO, please write N/A.


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Self-Identification Data Record

The purpose of this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The information on this survey is voluntary and will be kept confidential. Disclosure or refusal to provide the information will not subject you to any adverse treatment.

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: _______________

Invitation To Voluntarily Self-Identify 

The purpose of this request is to comply with certain federal Equal Opportunity and Affirmative Action obligations, including those promoted by the Vietnam Era Veterans’ Readjustment Assistance Act (VEVRAA) of 1974. Your participation is voluntary. Your failure or refusal to provide this information will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. 

VEVRAA Survey 

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. 

The Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), requires certain contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) 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. 

 

Invitation To Voluntarily Self-Identify 

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed. 


 
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