General Interest Form
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.
Self-Identification Survey
Please indicate if you belong to any of the following categories:- Disabled veteran
- Recently separated veteran
- Active duty wartime or campaign badge veteran
- Armed forces service medal veteran
About the Role
This position offers [job-specific details].
Responsibilities
Responsibilities include [job-specific tasks].
Requirements
Requirements include [job-specific qualifications].
Qualifications
Qualifications include [job-specific skills].
Skills
Skills required include [job-specific abilities].
Benefits
Benefits include [job-specific perks].
Pay
The salary range for this position is [salary range].
Schedule
The schedule for this position is [schedule details].
For government reporting purposes, we ask candidates to respond to the below self-identification survey.
Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring process or thereafter. Any information that you do provide will be recorded and maintained in a confidential file.
As set forth in WithumSmith+Brown’s Equal Employment Opportunity policy, we do not discriminate on the basis of any protected group status under any applicable law.
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.”
- Examples of major life activities include seeing, hearing, walking, breathing, performing manual tasks, caring for oneself, and working.
- 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)
- 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
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.