Voluntary Self-Identification of Disability
Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 05/31/2023
Why are you being asked to complete this form?
Hinshaw & Culbertson is committed to equal employment opportunity as well as creating and fostering a diverse and inclusive workplace; we resolutely believe that the differences among us strengthen our Firm. In order for the Firm to maintain accurate information about the diversity of our applicant pool and workforce, we encourage you to share details about yourself and your unique characteristics.
Submission of this information will not impact the terms or conditions of your application. Please be assured the information collected will be subject to access by a limited group of Firm personnel. By completing this form, you confirm that the information submitted is accurate and understand it may be used by Hinshaw & Culbertson for data collection and reporting purposes.
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.
How do you know if you have a disability?
For purposes of this survey, 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 impairment or medical condition or a person who is perceived by others as having such an impairment. Disabilities include, but are not limited to:
Please check one of the boxes 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.