FORM MUST B E COMPLETED IN FULL

Personal Information Oklahoma State University Complete form and email to: newhire@okstate.edu

Section 2: All NEW Employees Complete - Current Employees, Enter only fields that need updated

Marital Status Gender Hispanic? Birth Date (MMDDYYYY) White Asian

Black Amer Indian / Alaskan Natv

Native Hawaiian or Pacific Islander

Permanent Home Address (within USA to mail W-2)

Address Line 1 Telephone Number (w/ AC)

Address Line 2

City State Zip Code

Personal Email Account:

Emergency Contact

Contact Name Contact Relationship

Contact Address (Street Address, City, State, Zip Code) Contact Work Phone (w/ AC)

Contact Home Phone (w/ AC)

Section 3: All Faculty and Regular Staff Employees Must Complete

Educational Background **** List your HIGHEST degree or diploma first ****

Degree Year Rec'd Institution Name and Location Field of Study

This form only changes the basic employee demographic information in Banner and most benefits. This form does not change your beneficiary information or retirement provider information.

Employee Signature Telephone Number Date

Section 1: All Employees Complete

Prefix Last Name (incl suffix, e.g. Jr, Sr, III) First Name Middle Name Check if Name Change & attach a copy of new social security card & photo ID.

Citizen International Permanent Resident

Employee ID :

Citizenship Status: Biweekly Monthly

LOYALTY OATH FILING – instructions (51 O.S. §36.3)

WHERE TO FILE: • Every State officer shall be filed with the Secretary of State:

Secretary of State, Executive Legislative Division, 2300 N. Lincoln Blvd, Rm 101, Oklahoma City, OK 73105

• Every state employee shall be filed with the personnel officer of the

state entity employing the state employee.

• All other officers shall be filed with the office of the county clerk of the county of official residence of the officer.

• All other employees shall be filed with the office of the county clerk of

the county in which the entity employing the employee is located.

• Every notary public shall be filed with the office of the Secretary of State.

• All municipal officers or employees or school district officers or

employees shall be filed in the office of the municipal clerk of the municipality or in the office of the school clerk of the school district for which the officer or employee serves or by which the officer or employee is employed.

TO ENSURE PROPER FILING: Submit only the original oath with original signatures. Photo copies are not accepted. Type or print clearly in black ink: 1. List the name and address of the employing entity/board/commission. 2. Print the full and correct name of the person taking the oath 3. Name of the office, or if an employee, insert “an employee of_______ followed by the complete designation of the employing officer, agency, authority, commission, department or institution. Person taking the oath is the “Affiant”. ATTESTATION OF LOYALTY OATH: The Loyalty Oath must be signed and dated by a notary public or other officer authorized to administer oaths or affirmations (indicate title and rank, if other than a notary public) and include the identification of the jurisdiction in which the act is performed. The notary shall include the name of the individual making the statement (or taking the oath), the notary seal, commission expiration date and commission number. *Please retain a copy for your records before submitting the oath for filing with the Secretary of State. For additional information, please call 522-4565.

Name of State Agency, Authority, Commission, Department or Institution

________________________________________________________________ Address, City and Zip Code Agency, Authority, Commission, Department or Institution

________________________________________________________________

Print Name of State officer or Employee (Affiant)

LOYALTY OATH (51 O.S., 36.2A)

I do solemnly swear (or affirm) that I will support the Constitution and the laws of the United States of America and the Constitution and the laws of the State of Oklahoma, and that I will faithfully discharge, according to the best of my ability, the duties of my office or employment during such time as I am ________________________________________________________________ (Here put name of office, or, if an employee, insert "An Employee of " followed by the complete designation of the employing officer, agency, authority, commission, department or institution.)

_______________________________ Signature of Affiant

State of ____________________ County of __________________ Signed and sworn to (or affirmed) before me on this __________ day of ___________________, ________ by ________________________________. Print name of person taking the oath ________________________ Signature of Notary Public, or other officer authorized to administer oaths or affirmations.

(Seal, if any) _________________________ Title and Rank (if other than a Notary Public)

My Commission Expires:_______________

Commission Number: _________________

(OKSOS-08/2017)

HUMAN RESOURCES 106 Whitehurst

Stillwater, OK 74078 (405) 744-5449

Oklahoma Teachers’ Retirement System Notification Form

This form must be completed by ALL employees

Oklahoma Teachers’ Retirement System (OTRS) regulations state that employees participating in OTRS through their full-time employer must also participate through their part-time employer. Example: an adjunct or temporary employee hired at OSU and who is a participating OTRS employee at Stillwater Public Schools would mark “YES” in the first section below and indicate Stillwater Public Schools for the name of the institution.

Regulations also require OSU to remit employer-paid contributions for any employee who is retired and

currently receiving OTRS retirement income. If you are one of these retirees, answer “YES” you are retired

through OTRS.

If you have never participated in OTRS, mark “NO.”

If you are unsure if you are a current participating member of OTRS, please contact OTRS at (877) 738-6365.

For the above reasons, if you have a job or status change that could affect contributions to OTRS, please contact Human Resources to fill out another form.

□ YES, I participate in OTRS through my current or previous (please circle one) employer.

The name of the institution is: ______________________________________

I understand that per OTRS regulations, I must also contribute* 7% of my pay to OTRS while also employed at OSU. *only applicable if a current contributing OTRS member with another employer.

□ NO, I am NOT a participating member of OTRS through a full-time employer.

□ YES, I am an OTRS retiree, and currently receive a monthly retirement check from OTRS. Per OTRS

regulation, OSU must pay a fee to OTRS for retirees that return to work. Retirees must also be aware of any earning limits and ensure they do not exceed this limit or risk penalties towards their OTRS retirement pension. Please contact OTRS if you havequestions regarding your earning limits.

_______________________________ ________________ ______________________

Print Name Date of Birth Employee ID

______________________________________ ______________________ Signature Date

RETURN ORIGINAL FORM TO OSU BENEFITS, 106 WHITEHURST, STILLWATER, OK 74078

FOR OFFICE USE ONLY. EFFECTIVE DATE: _________________________

□ TRN, if current OTRS participant with another institution

□ TRX, if retired from OTRS

□ No action, if not a participant or retired with OTRS

______________________________ ________________________________ __________________

PRINT EMPLOYEE FULL NAME SIGNATURE OF EMPLOYEE DATE

Return original, signed form to OSU Benefits, 106 Whitehurst, and retain a copy for your records. Please keep all

beneficiary information current.

Employee’s Name: _____________________________ Campus-Wide ID: ____________________________

State of Oklahoma Outstanding Wages Beneficiary Designation

In accordance with Title 40, O.S., Section 165.3a, Oklahoma State University (OSU) offers its employees the option of designating a

beneficiary to receive the employee’s final check in the event of an employee’s death while an employee of OSU.

If you elect to name a beneficiary, you must complete the section below, Outstanding Wages Beneficiary Designation Form, and

submit to OSU Benefits, 106 Whitehurst. Should you desire to change your beneficiary at some point in the future, it will be your

responsibility to complete and submit to OSU Benefits, another Outstanding Wages Beneficiary Designation Form. For example, if

you name your spouse and are later divorced, you may want to complete a new form.

Primary Beneficiary: Receives priority distribution upon the employee’s death. Contingent Beneficiary: Receives distribution only

if the primary beneficiary(ies) are deceased at the time of the employee’s death.

If an employee does not elect to name a beneficiary, OSU’s payroll office will issue the employee’s final paycheck, including any

pay for unused annual/vacation leave, in accordance with Title 40, O.S., Section 165.3a, Payment of wages to surviving spouse and

children. Please be advised that if your final check is processed without the naming of a beneficiary, your surviving spouse, or if

there is no surviving spouse, your dependent children, or their guardians or the conservators of their estates, will receive in equal

shares a total up to the maximum $3,000 allowed by law. Any remaining payment would go into the estate and go through probate.

Please be advised that access to the funds processed to an estate may be delayed due to the probate process.

Primary Beneficiary Relationship:________________________

Full Name: ___________________________ DOB: (mm/dd/yyyy):__________________________

Social Security Number: _______________________

Address: _____________________________________________________________________________________

Street City State Zip Code

Beneficiary: Primary: ______ OR Contingent: ______ Relationship:________________________

Full Name: ___________________________ DOB: (mm/dd/yyyy):__________________________

Social Security Number: _______________________

Address: _____________________________________________________________________________________

Street City State Zip Code

Beneficiary: Primary: ______ OR Contingent: ______ Relationship:________________________

Full Name: ___________________________ DOB: (mm/dd/yyyy):__________________________

Social Security Number: _______________________

Address: _____________________________________________________________________________________

Street City State Zip Code

Beneficiary: Primary: ______ OR Contingent: ______ Relationship:________________________

Full Name: ___________________________ DOB: (mm/dd/yyyy):__________________________

Social Security Number: _______________________

Address: _____________________________________________________________________________________

Street City State Zip Code

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Oklahoma Withholding is now Updatable on Banner Self-Service

Employees may now change filing status (single, married or head of household), number of exemptions, and additional withholding amounts for Oklahoma payroll taxes on Banner Self Service.

On the employee tab of self service, click on benefits and deductions>>Oklahoma W-4 Tax Withholding. Follow the link at the top of the page by clicking on Oklahoma State Withholding Instructions.

To file Exempt from Oklahoma Taxes, to file other state taxes or other tax withholding questions, see Payroll Services Payroll Tax Withholding Forms and Instructions

Contact payroll.services@okstate.edu for help setting up or changing your Oklahoma withholding on self-service.

Please email to:

payroll.services@okstate.edu from your okstate.edu mailbox

or mail to: OSU Payroll Services 409 Whitehurst Stillwater, OK 74078 405-744-6372

PASTE PICTURE OF CHECK HERE Be sure the picture shows the numbers at the routing and account number at the bottom of the check

ATTENTION:

Official Use Only Oklahoma State University

AUTOMATIC DEPOSIT TRANSMITTAL This form is to be used by State and Higher Education Employees in communicating their direct deposit information.

Social Security D a te of Birth: MM/DD/YYYY / / Number:

First Name (limit to 15 characters)

Last Name (limit to 15 characters):

I hereby authorize the State of Oklahoma, as per the Oklahoma State Employee’s Direct Deposit Act, 74:292.10 to:

Account

Deposit my payroll warrant in my account as indicated below

REMOVE I understand that by terminating Direct Deposit for Payroll this will automatically terminate travel spending from my direct deposit account on file.

CHECKING SAVINGS ONLY ONE ACCOUNT MAY BE USED FOR DIRECT DEPOSIT

Financial Institution Name:

(Your Bank name) the fees and Routing Number Number the paycard.

PayCard

I have received and understand

conditions associated with

If monies to which I am not entitled are deposited to my account, I authorize the State of Oklahoma to direct the financial institution to return said funds. I understand the payroll date and frequency of payment currently being utilized by my employer will not be affected by my decision to use Payroll Direct Deposit.

Home MailingAddress:

City: Home Telephone

Number:

State: Work Telephone

Number:

ZIP:

Personal Email: Institution/

This This authority authority is is toto remainremain in in fullfull forceforce andand effect effect until:until: (A)(A) II givegive my my employeremployer writtwrittterminate terminate thisthis directdirect depositdeposit agreement.agreement. (B)(B) II failfail toto utilizeutilize payrollpayroll directdirect depositdeposit forfor 3636will will expire. expire. (C) (C) The The event event of of my my death, death, at at which which time time this this agreement agreement expires expires iiinformation information is is provided provided by by me me to to facilitate facilitate my my personal personal banking banking needs needs and and shall shall bbconfidence.confidence.

Signature:

en en notice notice using using this this form form (OPM-73) (OPM-73) toto 5 5 days, days, at at which which time time this this agreementagreement mmediately, mmediately, upon upon notification. notification. ThisThis e e considered considered personal personal and and held held inin

If this is a bank routing and/or account number addition or change please attach a voided check or an official document from your financial institution showing the financial institution’s routing number and your account number.

Date:

Location: Department:

/ /

Do not fill out or submit this form for change of Address or Name change.

1. Social Security Number Enter employee social security number.

2. Name Type or print employee name exactly as it appears on your account.

3. Type of Account Indicate whether your account is a checking or savings account or paycard. If paycard is selected see number 9.

4. Financial Institution Name Enter the name of the bank, savings and loan or credit union where your account is held, i.e.: Bank-One.

5. Financial Institution, City, State Enter the city and state of your financial institution.

6. Employing Agency Enter the name of the state agency you work for.

7. Signature and Date Sign and date the request form. NOTE-A request form cannot be processed without your signature as authorization.

8. Voided Check For deposit to a checking account, attach to this request a VOIDED check from the financial institution of your choice so that we can use the information to make a proper deposit. For a deposit to a savings account, provide a document from your financial institution showing the financial institution’s routing number and your account number. NOTE-A request form cannot be processed without this information. Thank you.

9. Paycard If paycard is selected, place the following information in the Financial Institution box: Way 2 Go Card, Comerica Bank, ABA 072000096

WHAT HAPPENS NEXT

When your payroll, spending, and/or travel reimbursement is included in the Direct Deposit system, or the Paycard you will receive a Notice of Deposit instead of a warrant. The pay stub will not change, you will continue to receive a record of your earnings.

If you should have any problems, follow the procedures listed below:

1. Call your bank and ask for Commercial Direct Deposit Assistance. Advise them that you are on direct depositthrough “ACH” (Automated Clearing House). If you still have problems, ask to speak to an Officer of the Bank,a Teller Supervisor or a Customer Service Representative. Write down the names of the people you talk to andthe phone number you called.

2. For Payroll DepositsIf you are not satisfied with the results for pay warrants, contact the payroll office of your employer, Direct DepositUnit. You must have completed Step 1 before calling the Direct Deposit Unit. We will need the Phone Numbers andNames of the people you talked with at your bank.

3. For Travel DepositsIf you are not satisfied with the results for travel warrants, contact your agency representative(s) who processes yourtravel claims.

4. For Spending Account DepositsIf you are not satisfied with the results for spending account warrants, contact Spending Accounts Administration atthe Employees Benefit Council (405) 232-1190.

5. For Paycard Deposits contact https://www.goprogram.com or 844-893-3121.

EMPLOYMENT STATUS (Check one) Employment Start Date: __________________

As a Government contractor subject to the VEVRAA we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran”. The following are definitions of “protected veterans”

1. 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 forthe receipt of military retired pay would be entitled to compensation) under laws administered by theSecretary of Veterans Affairs; or

a person who was discharged or released from active duty because of a service-connected disability.

2. A “recently separated veteran” means any veteran during the three-year period beginning on the date ofsuch veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

3. An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in theU.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaignbadge has been authorized under the laws administered by the Department of Defense.

4. 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 ArmedForces service medal was awarded pursuant to Executive Order 12985.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

DISABLED VETERAN

RECENTLY SEPARATED VETERAN

ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN

ARMED FORCES SERVICE MEDAL VETERAN

I am a protected veteran, but I choose not to self-identify the classifications to which I belong.

I am NOT a protected veteran.

Retirement/Release from Active Duty/Discharge Date: _________________

Signature Department

Date Campus Telephone Number

CONTINUED ON THE REVERSE

Full-time Continuous Part-time Continuous Full-time Temporary

Part-time Temporary Student Employee

Veteran Voluntary Self-Identification Form Page 1 of 2

CAMPUS WIDE ID # NAME (Print Last, First, Middle Initial)

3-24-2014

Veteran Voluntary Self-Identification Form Page 1 of 2

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for you disability.

Submission of this information is voluntary and refusal to provide it 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 Act of 1974, as amended.

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 conditionthat might require emergency treatment; and (iii) Government officials engaged in enforcing laws administeredby the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, maybe informed

Veteran Voluntary Self-Identification Form Page 2 of 2

☐

Voluntary Self-Identification of Disability Form CC-305 Page 1 of 1

OMB Control Number 1250-0005 Expires 05/31/2023

Name: Date: Employee ID:

(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 peoplewith disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individualswith 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• Autoimmune disorder, for example,

lupus, fibromyalgia, rheumatoidarthritis, or HIV/AIDS

• Blind or low vision• Cancer• Cardiovascular or heart disease• Celiac disease• Cerebral palsy

• Deaf or hard of hearing• Depression or anxiety• Diabetes• Epilepsy• Gastrointestinal disorders, for

example, Crohn's Disease, orirritable bowel syndrome

• Intellectual disability

• Missing limbs or partially missinglimbs

• Nervous system condition forexample, migraine headaches,Parkinson’s disease, or Multiplesclerosis (MS)

• Psychiatric condition, for example,bipolar disorder, schizophrenia,PTSD, or major depression

Please check one of the boxes below:

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability

☐ I Don’t Wish To Answer

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: _______________